07 Proceedings Cover and Spine:Layout 1 1/12/07 2:13 PM Page 1

2007 Annual Meeting

A bold new look for San Diego, California
AAOS matches our
brand promise

74th Annual Meeting Proceedings

T
he AAOS spent the last 18 months Look for a new visual identity system
in an intensive research and plan- that includes logos for the Academy
ning program exploring the and Association.
meaning and value of its brand. The Presi- • Keeping orthopaedics the focus, the new
dential Line, Board, Fellows, and specialty identity showcases our forward momentum
society leaders collaborated in these discus-
sions to provide a “big picture” of the past
and future of our brand.
The program defines the AAOS as a unify-
ing partner that brings together the best
and keeps AAOS at the forefront of ortho-
paedic education, advocacy, and research.
• Respecting the traditions and heritage of the
AAOS, the formal seal has been restored and
its use elevated—specifically for honorary
Proceedings
in orthopaedics under our mission
and ceremonial purposes.
and vision. With you, for you, the AAOS
develops flexible programs that give The 2007 Annual Meeting in San Diego is the
orthopaedic surgeons and their patients first opportunity where everything comes
solutions to more of the challenges together. Here, you will see our visual identity Meeting Dates
they face—creating the future of ortho- and experience quality education, technical February 14-18, 2007
paedics and advancing musculoskeletal exhibits, personal customer service, and the
health together. spirit of fellowship—the AAOS brand in action.
Exhibit Dates
February 14-16, 2007
2007 San Diego, CA
Volume 8
07 Proceedings Cover and Spine:Layout 1 1/12/07 2:13 PM Page 2

2007 Annual Meeting

San Diego, California
February 14-18
Call for
Abstracts
Applications to submit a poster presentation,
podium presentation, scientific exhibit or multimedia
education presentation are available on-line at

Proceedings www.aaos.org
Symposia Handouts Click on Annual Meeting, 2008 Abstract Submissions

Abstracts of: Submission deadline is June 4, 2007

Podium Presentations, Poster Presentations, Submission deadline for multimedia education
Scientific Exhibits, and Multimedia Education presentation is July 15, 2007

Board of Directors Members

Richard F. Kyle, MD Gordon M. Aamoth, MD Matthew S. Shapiro, MD
President Leslie L. Altick James P.Tasto, MD
James H. Beaty, MD Dwight W. Burney, III, MD Kristy Weber, MD
FirstVice President
John T. Gill, MD Stuart L.Weinstein, MD
E. Anthony Rankin, MD
Joseph C. McCarthy, MD KenYamaguchi, MD
SecondVice President
NormanY. Otsuka, MD Karen L. Hackett,
William L. Healy, MD
Andrew N. Pollak, MD FACHE, CAE
Treasurer
Chief Executive Officer

March 5 – 9, 2008
San Franciso, California
07 Proceedings Cover and Spine:Layout 1 1/12/07 2:13 PM Page 2

2007 Annual Meeting

San Diego, California
February 14-18
Call for
Abstracts
Applications to submit a poster presentation,
podium presentation, scientific exhibit or multimedia
education presentation are available on-line at

Proceedings www.aaos.org
Symposia Handouts Click on Annual Meeting, 2008 Abstract Submissions

Abstracts of: Submission deadline is June 4, 2007

Podium Presentations, Poster Presentations, Submission deadline for multimedia education
Scientific Exhibits, and Multimedia Education presentation is July 15, 2007

Board of Directors Members

Richard F. Kyle, MD Gordon M. Aamoth, MD Matthew S. Shapiro, MD
President Leslie L. Altick James P.Tasto, MD
James H. Beaty, MD Dwight W. Burney, III, MD Kristy Weber, MD
FirstVice President
John T. Gill, MD Stuart L.Weinstein, MD
E. Anthony Rankin, MD
Joseph C. McCarthy, MD KenYamaguchi, MD
SecondVice President
NormanY. Otsuka, MD Karen L. Hackett,
William L. Healy, MD
Andrew N. Pollak, MD FACHE, CAE
Treasurer
Chief Executive Officer

March 5 – 9, 2008
San Franciso, California
07 Proceedings Cover and Spine:Layout 1 1/12/07 2:13 PM Page 1

2007 Annual Meeting

A bold new look for San Diego, California
AAOS matches our
brand promise

74th Annual Meeting Proceedings

T
he AAOS spent the last 18 months Look for a new visual identity system
in an intensive research and plan- that includes logos for the Academy
ning program exploring the and Association.
meaning and value of its brand. The Presi- • Keeping orthopaedics the focus, the new
dential Line, Board, Fellows, and specialty identity showcases our forward momentum
society leaders collaborated in these discus-
sions to provide a “big picture” of the past
and future of our brand.
The program defines the AAOS as a unify-
ing partner that brings together the best
and keeps AAOS at the forefront of ortho-
paedic education, advocacy, and research.
• Respecting the traditions and heritage of the
AAOS, the formal seal has been restored and
its use elevated—specifically for honorary
Proceedings
in orthopaedics under our mission
and ceremonial purposes.
and vision. With you, for you, the AAOS
develops flexible programs that give The 2007 Annual Meeting in San Diego is the
orthopaedic surgeons and their patients first opportunity where everything comes
solutions to more of the challenges together. Here, you will see our visual identity Meeting Dates
they face—creating the future of ortho- and experience quality education, technical February 14-18, 2007
paedics and advancing musculoskeletal exhibits, personal customer service, and the
health together. spirit of fellowship—the AAOS brand in action.
Exhibit Dates
February 14-16, 2007
2007 San Diego, CA
Volume 8
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page i

6300 North River Road

Rosemont, Illinois 60018
P. 847.823.7186
F. 847.823.8125
www.aaos.org

Dear Colleagues:
Welcome to the AAOS 2007 Annual Meeting! A valuable tool and wonderful resource for future
reference is in these pages. In a collaborative effort, the Central Program Committee, Exhibits
Committee and the Multimedia Education Center Subcommittee have combined the abstracts
from selected scientific portions of the meeting for you.
The Proceedings Book and CD-Rom are sorted by symposia handouts followed by podium and
poster abstracts, scientific exhibit abstracts, and multimedia education abstracts all sorted by
classification.
We have also included:
• the subspecialty guide to the Annual Meeting identifying presentations by classification
• an author index
• a key word index
All in all, this is an excellent review of some of the most exciting topics presented at the 2007
Annual Meeting. We hope that you find this book useful now and in the future.
Sincerely,

Andrew H. Schmidt, MD Lynn A. Crosby, MD Gene R. Barrett, MD

Chair, Program Committee Chair, Exhibits Committee Chair, Multimedia Education
Center Subcommittee

i
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page ii

DISCLAIMER FDA STATEMENT

The material presented at the Annual Meeting has been Some drugs or medical devices demonstrated at the An-
made available by the American Academy of Or- nual Meeting have not been cleared by the FDA or have
thopaedic Surgeons for educational purposes only. been cleared by the FDA for specific purposes only. The
This material is not intended to represent the only, nor FDA has stated that it is the responsibility of the physi-
necessarily best, method or procedure appropriate for cian to determine the FDA clearance status of each drug
the medical situations discussed, but rather is intended or medical devices he or she wishes to use in clinical
to present an approach, view, statement or opinion of practice.
the faculty which may be helpful to others who face
similar situation. Academy policy provides that “off label” uses of a drug
or medical device may be described in the Academy’s
The AAOS disclaims any and all liability for injury or CME activities so long as the “off label” use of the drug
other damages resulting to any individuals attending a or medical device is also specifically disclosed (i.e. it
session for all claims, which may arise out of the use of must be disclosed that the FDA has not cleared the drug
the techniques demonstrated therein by such individu- or device for the described purpose). Any drug or med-
als, whether these claims shall be asserted by a physi- ical device is being used “off label” if the described use
cian or any other person. is not set forth on the products approval label.

No reproductions of any kind, including still photogra-

phy, audiotapes and videotapes, may be made of the
presentation at the Academy’s Annual Meeting. The Product Code # 02867
Academy reserves all of its rights to such material, and
Printed in the United States of America
commercial reproduction is specifically prohibited.

DISCLOSURE
Each participant in the Annual Meeting has been asked
to disclose if he or she has received something of value
from a commercial company or institution, which re-
lates directly or indirectly to the subject of their presen-
tation. The Academy has identified the options to
disclose as follows:

a. Research or institutional support has been re-

ceived;
b. Miscellaneous non-income support (e.g. equip-
ment or services);
c. Royalties;
d. Stock or stock options; or
e. Consultant or employee

n. Disclosed nothing of value received

An indication of the participant’s disclosure appears

after his or her name as does the commercial company
or institution that provided the support.

The Academy does not view the existence of these dis-

closed interests or commitments as necessarily imply-
ing bias or decreasing the value of the author’s
participation in the meeting.

ii
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page iii

TABLE OF CONTENTS
Subspecialty Guide to the Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Symposia Handouts
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Practice Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits

AAOS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Basic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Foot and Ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Pediatrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Practice Management/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
Sports Medicine and Arthroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
Allied Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
Regional Societies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727

Abstracts of Multimedia Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736

Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767

iii
 TA B L E O F C O N T E N T S

Subspecialty Guide to the Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Symposia Handouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits . . . . . . . . 359

Abstracts of Multimedia Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736

Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767

 WEDNESDAY, FEBRUARY 14

iv
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
ADULT RECONSTRUCTION HIP AND KNEE
Instructional Courses Skills 3, #102-3 #121 #142-3 #184 #162-3
Scientific Exhibits 7:00 AM-6:00 PM Hip SE01-SE16 Knee SE17-SE36
Adult Reconstruction Knee III: Complications
Adult Reconstruction Knee I: Adult Reconstruction Knee II: and TKR, Papers 91-105 Room 6B
FRONT MATTER 07:Layout 1

Adult Reconstruction Hip I:

Patellofemoral Replacement and Technique, Pain Control and Unique Adult Reconstruction Hip II: New Technology:
Scientific Papers Revision and Complications,
Mobile Bearing Knees, Compartment Replacement, Resurfacing THA, Navigation, Minimally
Papers 16-30 Room 6B Invasive Approaches,
Papers 1-15 Room 6B Papers 76-90 Room 7
Papers 121-135 Room 6DE

Scientific Posters 7:00 AM-6:00 PM Hip P001-P110 Knee P111-P206

1/12/07

Hot Topics and Controversies in

Symposia Primary THA (A) Ballroom 20
BASIC RESEARCH
Instructional Courses #145
1:56 PM

Scientific Exhibits 7:00 AM-6:00 PM SE37-SE41, SE69, SE78

FOOT AND ANKLE
Instructional Courses #106 #126 #146 #166
Scientific Exhibits 7:00 AM-6:00 PM SE42-SE44
Page iv

Foot/Ankle I: Ankle Arthroplasty and

Scientific Papers Arthrodesis, Papers 61-75 Room 6DE
Scientific Posters 7:00 AM-6:00 PM P207-P225
Controversies and New Operative Techniques Cartilage Reconstruction of the
Symposia for the Treatment of Common Foot and
Ankle Operative Procedures (D) Room 6CF Ankle Joint (F) Room 6CF

GENERAL
Instructional Courses #101 #141 #161
Benchtop to Bedside: Examining the Barriers
Symposia Between the Research Laboratory and the
Clinical Setting (E) Room 6CF

HAND AND WRIST

Instructional Courses #147 #167

Scientific Exhibits 7:00 AM-6:00 PM SE45-SE46

Scientific Posters 7:00 AM-6:00 PM P226-P244

PRACTICE MANAGEMENT/NONCLINICAL
Instructional Courses #107 #123 #152-3 #171

Scientific Exhibits 7:00 AM-6:00 PM SE47-SE49, SE71, SE72, SE74

Scientific Posters 7:00 AM-6:00 PM P266-P281

PEDIATRICS
Instructional Courses #108 #122, 128 #148 #168
SUBSPECIALTY GUIDE TO ANNUAL MEETING

Scientific Posters 7:00 AM-6:00 PM P245-P265

 REHABILITATION MEDICINE
Instructional Courses
Scientific Exhibits 7:00 AM-6:00 PM SE50
Scientific Posters 7:00 AM-6:00 PM P282-P292
SHOULDER AND ELBOW
FRONT MATTER 07:Layout 1

Instructional Courses Skills 4 #182 #124, 129 #149 #169, 172

Scientific Exhibits 7:00 AM-6:00 PM SE51
Shoulder/Elbow I: Arthroplasty,
Scientific Papers Papers 31-45 Room 6B
Scientific Posters 7:00 AM-6:00 PM P293-P353
1/12/07

Treatment of Rotator Cuff Disease:

Symposia An International Perspective on the Burden
of Evidence (C) Ballroom 20

SPINE
#110 #130 #150 #170
1:56 PM

Instructional Courses
Scientific Exhibits 7:00 AM-6:00 PM SE52-SE55
Spine I: Cervical Spine, Spine II: Spinal Deformity,
Scientific Papers Papers 46-60 Room 6A Papers 106-120 Room 6A
Page v

Scientific Posters 7:00 AM-6:00 PM P354-P409

Spondylolisthesis: Current Knowledge and AAOS/ORS II: Total Disc Arthroscopy:
Symposia Treatment Options (B) Room 6CF The Art and Science as of 2007 Room 6A
SPORTS MEDICINE/ARTHROSCOPY
Instructional Courses #109 #131 #151 #186 #165

Scientific Exhibits 7:00 AM-6:00 PM SE56-SE61, SE76

Scientific Posters 7:00 AM-6:00 PM P410-P460

TRAUMA
Instructional Courses #104 #181 #127 #144 #185 #164
Scientific Exhibits 7:00 AM-6:00 PM SE62-SE66, SE75
Trauma I: General,
Scientific Papers Papers 136-150 Room 7
Scientific Posters 7:00 AM-6:00 PM P461-P526
AAOS/ORS I Orthopaedic War Injuries from
Combat Casualty Care to Definitive Treatment:
Symposia A Current Review of the Basic Science,
Clinical Advances and Research Opportunities
Room 6A
TUMOR/METABOLIC DISEASE
Instructional Courses #105 #125

Scientific Exhibits 7:00 AM-6:00 PM SE67-SE68, SE70, SE73, SE77

Scientific Posters 7:00 AM-6:00 PM P527-P552

SUBSPECIALTY GUIDE TO ANNUAL MEETING

v
 THURSDAY, FEBRUARY 15

vi
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
ADULT RECONSTRUCTION HIP AND KNEE
Instructional Courses #201-3 #222-3 #242-3 #262-3
Scientific Exhibits 7:00 AM-6:00 PM Hip SE01-SE16 Knee SE17-SE36

Adult Reconstruction Hip III: Adult Reconstruction Hip IV: New Bearings; Adult Reconstruction Knee IV:
FRONT MATTER 07:Layout 1

Scientific Papers Primary Total Hip Arthroplasty, Bearing Surface Wear, Outcomes and TKR,
Papers 151-165 Room 6A Papers 196-210 Room 6A Papers 286-300 Room 7

Scientific Posters 7:00 AM-6:00 PM Hip P001-P110 Knee P111-P206

Controversial Issues and Hot Topics in Early Perioperative Complications

1/12/07

Symposia Primary Total Knee Replacement (K) of THR: Contemporary Prevention and
Ballroom 20 Treatment (N) Room 6CF
BASIC RESEARCH
Instructional Courses #225 #245
1:56 PM

Scientific Exhibits 7:00 AM-6:00 PM SE37-SE41, SE69, SE78

FOOT AND ANKLE
Instructional Courses #281 #246 #266

Scientific Exhibits 7:00 AM-6:00 PM SE42-SE44

Page vi

Foot/Ankle II: Miscellaneous,

Scientific Papers Papers 166-180 Room 6DE

Scientific Posters 7:00 AM-6:00 PM P207-P225

GENERAL

Instructional Courses #282 #221 #241 #272

HAND AND WRIST

Instructional Courses #207 #227 #247 #267
Scientific Exhibits 7:00 AM-6:00 PM SE45-SE46
Scientific Posters 7:00 AM-6:00 PM P226-P244
What Every Resident Should Know About
Symposia Hand Surgery (EE) Room 25C
PRACTICE MANAGEMENT/NONCLINICAL
Instructional Courses #212-3 298 (12:30 PM) #226 #252 #261, 269
Scientific Exhibits 7:00 AM-6:00 PM SE47-SE49, SE71, SE72, SE74
Practice/Rehab I: Papers 316-330
Scientific Papers Room 6A
Scientific Posters 7:00 AM-6:00 PM P266-P281
The Clinician and Industry Relationship:
Symposia Conflict versus Collaboration (L)
Room 6CF
PEDIATRICS
Instructional Courses Skills 6, #208 #228 #248 Skills 7 #268
SUBSPECIALTY GUIDE TO ANNUAL MEETING

Pediatrics I: Perioperative Care and Spine, Pa- Pediatrics II: Trauma/Hip,

Scientific Papers pers 271-285 Room 6DE Papers 331-345 Room 6DE
Scientific Posters 7:00 AM-6:00 PM P245-P265
 REHABILITATION MEDICINE
Instructional Courses
Scientific Exhibits 7:00 AM-6:00 PM SE50
Scientific Posters 7:00 AM-6:00 PM P282-P292
SHOULDER AND ELBOW
FRONT MATTER 07:Layout 1

Instructional Courses Skills 5, #209, 211 #229, 231 #249

Scientific Exhibits 7:00 AM-6:00 PM SE51
Shoulder/Elbow II: Rotator Cuff,
Scientific Papers Papers 241-255 Room 6B
P293-P353
1/12/07

Scientific Posters 7:00 AM-6:00 PM

Controversies in the Management
Symposia of Proximal Humerus Fractures (M)
Ballroom 20
SPINE
1:56 PM

Instructional Courses #210 #250 #286 #270

Scientific Exhibits 7:00 AM-6:00 PM SE52-SE55
Spine III: Lumbar Spine,
Scientific Papers Papers 211-225 Room 6DE
Scientific Posters 7:00 AM-6:00 PM P354-P409
Page vii

Degenerative Disc (H)

Symposia Room 6CF
SPORTS MEDICINE/ARTHROSCOPY
Instructional Courses #206 #283 #230 #251 #284 #271
Scientific Exhibits 7:00 AM-6:00 PM SE56-SE61, SE76
Sports/Arthroscopy I: Cartilage Healing/ ACL,
Scientific Papers Papers 181-195 Room 7
Scientific Posters 7:00 AM-6:00 PM P410-P460
Symposia MRI-Arthroscopy Correlation (J) Room 6CF
TRAUMA
Instructional Courses #204 #224 #244 #285 #264

Scientific Exhibits 7:00 AM-6:00 PM SE62-SE66, SE75

Trauma II: Femur and Upper Extremity, Trauma III: Hip and Pelvis,
Scientific Papers Papers 346-360 Room 7
Papers 226-240 Room 7

Scientific Posters 7:00 AM-6:00 PM P461-P526

TUMOR/METABOLIC DISEASE
Instructional Courses #205 #265
Scientific Exhibits 7:00 AM-6:00 PM SE67-SE68, SE70, SE73, SE77
Tumor/Metabolic Disease I: Metastatic Disease, Tumor and Metabolic Disease II:
Scientific Papers Metabolic Bone Disease, Other Conditions, Pa- Bone and Soft Tissue Sarcomas,
pers 256-270 Room 6A Papers 301-315 Room 6B
Scientific Posters 7:00 AM-6:00 PM P527-P552 AAOS sessions will be held at the San Diego Con-
All Scientific Exhibits and Poster Presentations will be
Controversies in the Management of vention Center (SDCC), and the San Diego Mar-
Symposia held at the San Diego Convention Center, Sails Pavilion.
Metastases to Bone (G) Room 6B riott Hotel and Marina.
SUBSPECIALTY GUIDE TO ANNUAL MEETING

vii
viii
FRIDAY, FEBRUARY 16
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
ADULT RECONSTRUCTION HIP AND KNEE
Instructional Courses #302-3 #381 #321-2 #341-3 #384 #362
Scientific Exhibits 7:00 AM-6:00 PM Hip SE01-SE16 Knee SE17-SE36
FRONT MATTER 07:Layout 1

Adult Reconstruction Hip V:

Nonarthroplasty Operative Treatments,
Economic Issues, Miscellaneous,
Scientific Papers Papers 466-480 Room 6B
Adult Reconstruction Knee V: MIS/CAOS,
1/12/07

Papers 496-510 Room 6DE

Scientific Posters 7:00 AM-6:00 PM Hip P001-P110 Knee P111-P206

Dislocation After Total Hip Arthroplasty:
Symposia World Perspectives (U) Ballroom 20
1:56 PM

BASIC RESEARCH
Instructional Courses #365
Scientific Exhibits 7:00 AM-6:00 PM SE37-SE41, SE69, SE78
FOOT AND ANKLE
Page viii

Instructional Courses #306 #326

Scientific Exhibits 7:00 AM-6:00 PM SE42-SE44
Scientific Posters 7:00 AM-6:00 PM P207-P225
GENERAL
Instructional Courses #301 #361
Techniques for Tibial Deformity Correction:
Symposia State of the Art (R) Room 6A

HAND AND WRIST

Instructional Courses #307 #382 #327 #347 #367
Scientific Exhibits 7:00 AM-6:00 PM SE45-SE46
Hand and Wrist I: Nerve, Tendon and Wrist Hand and Wrist II: Trauma and OA,
Scientific Papers Stability, Papers 361-375 Room 6A Papers 406-420 Room 6B
Scientific Posters 7:00 AM-6:00 PM P226-P244
Symposia Compressive Neuropathies in 2007 (Q) Room 6B

PRACTICE MANAGEMENT/NONCLINICAL
Instructional Courses #311-2 #383 #329 #346
Scientific Exhibits 7:00 AM-6:00 PM SE47-SE49, SE71, SE72, SE74
Scientific Posters 7:00 AM-6:00 PM P266-P281
Symposia Maintenance of Certification (O) Room 6B

PEDIATRICS
Instructional Courses #308 #330-1 #345, 348 #368
Pediatrics III: General,
Scientific Papers Papers 376-390 Room 6DE
Scientific Posters 7:00 AM-6:00 PM P245-P265
SUBSPECIALTY GUIDE TO ANNUAL MEETING

What's New in Pediatric Orthopaedics: Pediatric Fractures, Common Pitfalls

Symposia Management of Sports Injuries in the and Management Strategies (X)
Adolescent Athlete (V) Room 6CF Room 6CF
 REHABILITATION MEDICINE
Instructional Courses
Scientific Exhibits 7:00 AM-6:00 PM SE50
Scientific Posters 7:00 AM-6:00 PM P282-P292
FRONT MATTER 07:Layout 1

SHOULDER AND ELBOW

Instructional Courses Skills 9, #309 #323 #349 #366, 369

Scientific Exhibits 7:00 AM-6:00 PM SE51

1/12/07

Shoulder and Elbow III: Rotator Cuff/ Shoulder and Elbow IV: Proximal Humerus Fracture/
Scientific Papers Instability/Brachial Plexus, Papers 391-405 Misc Shoulder and Elbow, Papers 451-465
Room 7 Room 7
Scientific Posters 7:00 AM-6:00 PM P293-P353
SPINE
1:56 PM

Instructional Courses #310 #352 #370

Scientific Exhibits 7:00 AM-6:00 PM SE52-SE55
Spine IV: Spine Fusion and Arthroplasty,
Scientific Papers Papers 436-450 Room 6DE
Page ix

Scientific Posters 7:00 AM-6:00 PM P354-P409

SPORTS MEDICINE/ARTHROSCOPY
Instructional Courses #328 #350-1 #371
Scientific Exhibits 7:00 AM-6:00 PM SE56-SE61, SE76
Sports/Arthroscopy II: Arthroscopy, Knee, Sports/Arthroscopy III: Hip and Shoulder,
Scientific Papers Papers 421-435 Room 6A Papers 481-495 Room 6A
Scientific Posters 7:00 AM-6:00 PM P410-P460
Decision-Making and Effective Arthroscopic
Symposia Techniques in the Management of
Shoulder Instability (P) Room 6CF

TRAUMA
Instructional Courses Skills 8, #304 #324 #344 #385 #363-4
Scientific Exhibits 7:00 AM-6:00 PM SE62-SE66, SE75
Trauma IV: Lower Extremity,
Scientific Papers Papers 511-525 Room 7
Scientific Posters 7:00 AM-6:00 PM P461-P526
Changing Face of Orthopaedic Trauma (S) Room 6CF Fractures about the Knee: New Treat-
Symposia From Iraq - Back to Iraq: ment Methods and Stabilization Choices
Modern Combat Orthopaedic Care (T) Room 6DE (W) Ballroom 20

TUMOR/METABOLIC DISEASE
Instructional Courses #305 #325 #386

Scientific Exhibits 7:00 AM-6:00 PM SE67-SE68, SE70, SE73, SE77

Scientific Posters 7:00 AM-6:00 PM P527-P552

SUBSPECIALTY GUIDE TO ANNUAL MEETING

ix
x
SATURDAY, FEBRUARY 17
7:00 AM - 5:30 PM 7:00 AM - 5:30 PM (Times Vary)
ADULT RECONSTRUCTION HIP AND KNEE
Hip Society/AAHKS, San Diego Marriott, Salon 1
Knee Society/AAHKS, San Diego Marriott, Salon 4
FRONT MATTER 07:Layout 1

Specialty Day
Limb Lengthening and Reconstruction Society, SDCC, Room 32A

Scientific Exhibits 7:00 AM - 5:30 PM Hip SE01-SE16 Knee SE17-SE36

1/12/07

Scientific Posters 7:00 AM - 5:30 PM Hip P001-P110 Knee P111-P206

1:56 PM

BASIC RESEARCH

Scientific Exhibits 7:00 AM - 5:30 PM SE37-SE41, SE69, SE78

Page x

FOOT AND ANKLE

American Orthopaedic Foot and Ankle Society,
Specialty Day SDCC, Room 6B

Scientific Exhibits 7:00 AM - 5:30 PM SE42-SE44

Scientific Posters 7:00 AM - 5:30 PM P207-P225

HAND AND WRIST

American Society for Surgery of the Hand/
Specialty Day American Association for Hand Surgery, SDCC, Room 28A

Scientific Exhibits 7:00 AM - 5:30 PM SE45-SE46

Scientific Posters 7:00 AM - 5:30 PM P226-P244

NONCLINICAL/PRACTICE MANAGEMENT/LIFESTYLES
Scientific Exhibits 7:00 AM - 5:30 PM SE47-SE49, SE71, SE72, SE74

Scientific Posters 7:00 AM - 5:30 PM P266-P281

PEDIATRICS

Pediatric Orthopaedic Society of North America,

Specialty Day SDCC, Room 33A
SUBSPECIALTY GUIDE TO ANNUAL MEETING

Scientific Posters 7:00 AM - 5:30 PM P245-P265

 REHABILITATION MEDICINE
Specialty Day Orthopaedic Rehabilitation Association, SDCC, Room 30D
Scientific Exhibits 7:00 AM - 5:30 PM SE50
Scientific Posters 7:00 AM - 5:30 PM P282-P292
FRONT MATTER 07:Layout 1

SHOULDER AND ELBOW

Specialty Day American Shoulder and Elbow Surgeons, SDCC, Room 6A

1/12/07

Scientific Exhibits 7:00 AM - 5:30 PM SE51

Scientific Posters 7:00 AM - 5:30 PM P293-P353

SPINE
1:56 PM

Specialty Day Federation of Spine Associations, SDCC, Room 6D

Scientific Exhibits 7:00 AM - 5:30 PM SE52-SE55

Page xi

Scientific Posters 7:00 AM - 5:30 PM P354-P409

SPORTS MEDICINE/ARTHROSCOPY
Arthroscopy Association of North America, SDCC, Room 20C
Specialty Day
American Orthopaedic Society for Sports Medicine, SDCC, Room 20A

Scientific Exhibits 7:00 AM - 5:30 PM SE56-SE61, SE76

Scientific Posters 7:00 AM - 5:30 PM P410-P460

TRAUMA

Specialty Day Orthopaedic Trauma Association, SDCC, Room 6C

Scientific Exhibits 7:00 AM - 5:30 PM SE62-SE66, SE75

Scientific Posters 7:00 AM - 5:30 PM P461-P526

TUMOR/METABOLIC DISEASE
Specialty Day Musculoskeletal Tumor Society, SDCC, Room 8
Scientific Exhibits 7:00 AM - 5:30 PM SE67-SE68, SE70, SE73, SE77
Scientific Posters 7:00 AM - 5:30 PM P527-P552
* Specialty Society Programs start and end times vary, check the Specialty Day Program for specific times.
Specialty Day Sessions will be held at the San Diego Convention Center (SDCC) and the
San Diego Marriott Hotel and Marina.
SUBSPECIALTY GUIDE TO ANNUAL MEETING

xi
xii
SUNDAY, FEBRUARY 18
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM
ADULT RECONSTRUCTION HIP AND KNEE
Instructional Courses #401 #481 #421-2
FRONT MATTER 07:Layout 1

Scientific Exhibits 7:00 AM-12:30 PM Hip SE01-SE16 Knee SE17-SE36

Scientific Posters 7:00 AM-12:30 PM Hip P001-P110 Knee P111-P206

1/12/07

What to do when Total Knee Arthroplasties Fail?

Minimally invasive Challenges and Controversies (BB) Room 6B
Symposia Total Knee Replacement (FF)
Room 6CF MIS Total Hip Replacement: The Good, the Bad,
and the Ugly (CC) Room 6A
1:56 PM

BASIC RESEARCH

Scientific Exhibits 7:00 AM-12:30 PM SE37-SE41, SE69, SE78

Page xii

FOOT AND ANKLE

Scientific Exhibits 7:00 AM-12:30 PM SE42-SE44

Scientific Posters 7:00 AM-12:30 PM P207-P225

HAND AND WRIST

Instructional Courses #407 #427

Scientific Exhibits 7:00 AM-12:30 PM SE45-SE46

Scientific Posters 7:00 AM-12:30 PM P226-P244

Complications of Distal Radius Fractures (Z)
Symposia Room 6A

PRACTICE MANAGEMENT/NONCLINICAL
Scientific Exhibits 7:00 AM-12:30 PM SE47-SE49, SE71, SE72, SE74

Scientific Posters 7:00 AM-12:30 PM P266-P281

PEDIATRICS

Instructional Courses #403

SUBSPECIALTY GUIDE TO ANNUAL MEETING

Scientific Posters 7:00 AM-12:30 PM P245-P265

 REHABILITATION MEDICINE
Scientific Exhibits 7:00 AM-12:30 PM SE50

Scientific Posters 7:00 AM-12:30 PM P282-P292

FRONT MATTER 07:Layout 1

SHOULDER AND ELBOW

Instructional Courses #405 #425
Scientific Exhibits 7:00 AM-12:30 PM SE51
1/12/07

Scientific Posters 7:00 AM-12:30 PM P293-P353

Prevention and Treatment of Complications from
Symposia Elbow Fractures: Pearls and Pitfalls (DD) Room 6DE

SPINE
1:56 PM

Instructional Courses #402 #426

Scientific Exhibits 7:00 AM-12:30 PM SE52-SE55

Scientific Posters 7:00 AM-12:30 PM P354-P409

Page xiii

SPORTS MEDICINE/ARTHROSCOPY

Instructional Courses #406 #482 #424

Scientific Exhibits 7:00 AM-12:30 PM SE56-SE61, SE76

Scientific Posters 7:00 AM-12:30 PM P410-P460

Evidence Based Decision Making in

Symposia Sports Medicine (Y) Room 6B

TRAUMA
Instructional Courses #404 #423
Scientific Exhibits 7:00 AM-12:30 PM SE62-SE66, SE75
Scientific Posters 7:00 AM-12:30 PM P461-P526

Managing Hip Fractures in the Osteoporotic

Symposia Patient: What is the Evidence? (AA)
Room 6DE

TUMOR/METABOLIC DISEASE

Scientific Exhibits 7:00 AM-12:30 PM SE67-SE68, SE70, SE73, SE77

Scientific Posters 7:00 AM-12:30 PM P527-P552

SUBSPECIALTY GUIDE TO ANNUAL MEETING

xiii
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page xiv

Call for
Abstracts
Applications to submit a poster presentation,
podium presentation, scientific exhibit or multimedia
education presentation are available on-line at

www.aaos.org
Click on Annual Meeting, 2008 Abstract Submissions

Submission deadline is June 4, 2007

Submission deadline for multimedia education
presentation is July 15, 2007

March 5 – 9, 2008
San Franciso, California

xiv
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page 1

2007 ANNUAL MEETING COMMITTEES

EXHIBITS The following AAOS Committees are responsible for the scientific program, the scientific exhibits
and the multimedia education program. They grade abstracts, suggest moderators, identify hot
COMMITTEE topics and evaluate sessions all in an effort to bring you an exciting and innovative program.
Lynn A. Crosby, MD, Dayton, OH, Chair
(a – DePuy, Exactech, d – Exactech, CENTRAL PROGRAM SUB-COMMITTEE MEMBERS
f – Wright State Physician) ADULT RECONSTRUCTION HIP L. Andrew Koman, MD, Winston-Salem, NC
Hugh U. Cameron, MD, Toronto, Canada William A. Jiranek, MD, Richmond, VA, Chair (a – Allergan, Soltic, Orthofix, b – Allergan,
(c, e – DePuy) (a – Brainlab, Lifenet, d – DePuy, e – Zimmer, Soltic, Orthofix, d – Kinetics Concepts, Zimmer,
DePuy, Lifenet) Orthofix)
A. Seth Greenwald, D. Phil (Oxon),
Cleveland, OH (n) Ronald Emilio Delanois, MD, Chesapeake, VA
(n) SHOULDER AND ELBOW
Michael H. Huo, MD, Dallas, TX Marc Safran, MD, San Francisco, CA, Chair
(e – Stryker, Zimmer, f – American William J. Hozack, MD, Philadelphia, PA
(a – Smith & Nephew, Histogenics)
Association of Hip & Knee Surgeons Board (e – Stryker)
Carl J. Basamania, MD, Durham, NC
Member) Seth S. Leopold, MD, Seattle, WA
(c, e – DePuy Orthopaedics)
Adolph V. Lombardi, Jr., MD, New Albany, (a, e – Zimmer)
Norman Douglas Boardman, III, MD,
OH (d, e – Biomet) Thomas A. Malvitz, MD, Grand Rapids, MI
Richmond, VA (b – Biomet, DePuy, Johnson &
Alfonso Mejia, MD, Chicago, IL (n) (e – Zimmer)
Johnson, Tornier, e – DePuy, Johnson &
Michael P. Mott, MD, Warren, MI (n) Charles L. Nelson, MD, Voorhees, NJ Johnson)
Martin Plotkin, MD, St. Charles, IL (n) (c – Exactech, e – Zimmer)
David A. Detrisac, MD, Okemos, MI (n)
Michael D. Ries, MD, San Francisco, CA Michael L. Parks, MD, New York, NY
Laurence D. Higgins, MD, Durham, NC
(c - Smith & Nephew, Inc.) (a, d, e – Zimmer)
(a – Zimmer, Mitek, c – Zimmer)
Jeffrey L. Visotsky, MD, Des Plaines, IL Michael D Ries, MD, San Francisco, CA
R. Kumar Kadiyala, MD, Iowa City, IA
(b, e – DePuy, f – Emedicine.com) (c – Smith & Nephew)
(e – EBI Medical)
ADULT RECONSTRUCTION KNEE
SPINE
MULTIMEDIA EDUCATION Robert T. Trousdale, MD, Rochester, MN, Chair
Howard S. An, MD Chicago, IL, Chair
(n)
CENTER SUBCOMMITTEE William T. Ballard, MD, Chattanooga, TN
(a – Medtronics, DePuy Spine, Zimmer Spine,
Gene R. Barrett, MD, Jackson, MS, Chair e – Stryker, Zimmer Spine, f – Spine, American
(b, e – Johnson & Johnson) J Orthopaedics)
(n)
Craig Howard Bennett, MD, Timonium, MD (n) John A. Glaser, MD, Charleston, SC
Nicholas A. Abidi, MD, Santa Cruz, CA
Henry D. Clarke, MD, New York, NY (a – Synthes)
(e – DePuy Orthopaedics)
(b – DePuy, e – Zimmer, f – AAOS, JBJS, Journal William J. Richardson, MD, Durham, NC (n)
Animesh Agarwal, MD, San Antonio, TX of Knee Surgery, Techniques in Knee Surgery)
(a – Smith & Nephew; e - Synthes) Vincent J. Silvaggio, MD, Pittsburgh, PA
Andrew A. Freiberg, MD, Boston, MA (e – Glubus Medical)
Richard E. Bowen, MD, Los Angeles, CA (a – Zimmer, Biomet, c – Zimmer)
(n) Andrew V. Slucky, MD, Alameda, CA
Michael A. Kelly, MD, New York, NY (a – Medtronic, Synthes, b – Synthes,
Ty Henry Goletz, MD, San Antonio, TX (c, e – Zimmer)
(e – DePuy, Inc.) d – Medtronic)
Todd Kevin Gothelf, MD, New South FOOT AND ANKLE Susan E. Stephens, MD, Cleveland, OH
Wales, Australia (n) (e – Blackstone Medical)
John Gould, MD, Birmingham, AL, Chair
Spero G. Karas, MD, Atlanta, GA (e – Zimmer)
SPORTS MEDICINE/ARTHROSCOPY
(e – Encore Medical Corporation) Paul T. Fortin, MD, Royal Oak, MI (n) Ronald M. Selby, MD, New York, NY, Chair (n)
Kevin D. Plancher, MD, New York, NY (n) Norman Turner, III, MD, Rochester, MN (n) James N. Gladstone, MD, New York, NY (n)
Richard Uhl, MD, Albany, NY (n) Steven B. Weinfeld, MD, New York, NY (n) Mark J. Lemos, MD, Carlisle, MA (n)
Steven T. Woolson, MD, Palo Alto, CA Thomas N. Lindenfeld, MD, Cincinnati, OH (n)
(e - DePuy, Inc.) HAND AND WRIST
Richard A. Berger, MD, Rochester, MN, Chair Ronald Anthony Navarro, MD, Harbor City, CA
(c – SBI) (a – Clearant, Inc.)
CENTRAL PROGRAM David L. Cannon, MD, Chesapeake, VA (n) Lawrence Wells, MD, Philadelphia, PA (n)
COMMITTEE Matthew D. Putnam, MD, Minneapolis, MN
TRAUMA
Andrew H. Schmidt, MD, Plymouth, MN, (a – Wright Medical, Smith and Nephew, Synthes,
b – Wright Medical, c – Small Bone Innovations, d Kenneth Koval, MD, Lebanon, NH, Chair
Chair (a - Synthes USA, d - Twin Star (c – EBI Medical, e – Stryker)
Medical, e – Smith & Nephew, Depuy) – Boundary Medical, Wright Medical,
e – Wright Medical, Small Bone Innovations) Gary S. Gruen, MD, Pittsburgh, PA
Daniel J. Berry, MD, Rochester, MN (a – Smith & Nephew)
(a, c – DePuy, a – Zimmer, Stryker) Thomas Trumble, MD, Seattle, WA (n)
Brent L. Norris, MD, Chattanooga, TN (n)
Scott D. Boden, MD, Atlanta, GA PEDIATRICS
(a, e – Medtronic, b, c – Osteotech) Andrew N. Pollak, MD, Baltimore, MD (n)
Lori A. Karol, MD, Dallas, TX, Chair (n) Edward C. Yang, MD, Elmhurst, NY (n)
Alan L. Jones, MD, Dallas, TX Frances A. Farley MD, Ann Arbor, MI (n)
(a – Synthes America)
Martin Herman, MD, Yardley, PA (n) TUMOR & METABOLIC DISEASE
William J. Maloney, MD, Stanford, CA Kristy L. Weber, MD, Baltimore, MD, Chair (n)
(a – DePuy, Medtronics, c – Zimmer, PRACTICE MANAGEMENT/NONCLINICAL
Wright Medical) Janet Sybil Biermann, MD, Ann Arbor, MI (n)
James M. Fox, MD, Van Nuys, CA
J. Sybil Biermann, MD, Ann Arbor, MI, John E. Ready, MD, Boston, MA (n)
(c – Smith & Nephew, e – Sanofi)
BOS Representative (n) Shawn Patrick Granger, MD, Leesville, LA (n)
The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed.
For fullinformation, refer to page iv.
1
FRONT MATTER 07:Layout 1 1/12/07 1:56 PM Page 2

This Proceedings Book is divided into three sections, Symposia Scientific Exhibits have been grouped in the following categories:
SCIENTIFIC PROGRAM, SCIENTIFIC EXHIBITS AND MULTIMEDIA EDUCATION

handouts and then Podium Presentations, Poster Exhibits, and

• Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE01 – SE16
Scientific Exhibits by classification and finally Multimedia
• Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE17 – SE36
Education.
• Basic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE37 – SE41
• Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . .SE42 – SE44
PODIUM PRESENTATIONS • Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . .SE45 – SE46
The Scientific Program features 525 podium presentations. All • Practice Management . . . . . . . . . . . . . . . . . . . . . .SE47 – SE49
podium presentations are six minutes in groups of three • Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE50
followed by an open floor discussion moderated by chosen • Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE51
Academy members. The Scientific Program takes place at the San • Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE52 – SE55
Diego Convention Center at various times and locations, please • Sports Medicine and Arthroscopy . . . . . . . . . . . .SE56 – SE61
see the final program for the schedule. • Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE62 – SE66
• Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE67 – SE68
• AAOS Committees . . . . . . . . . . . . . . . . . . . . . . . . .SE69 – SE75
POSTER EXHIBITS
• BOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE76 – SE78
Five hundred and sixty-three Poster Exhibits will be presented
during the Annual Meeting. All Poster Exhibits will be displayed MULTIMEDIA EDUCATION
the entire five days of the meeting. Included in these are Board of Orthopaedic education benefits greatly from visual examples.
Specilaty Societies (BOS) posters. The BOS posters will be Observe, compare, and evaluate video demonstrations of classic
indicated by their Society’s name or the name of their and modern techniques in orthopaedic surgery. Study award-
presentation. The Program also features selected posters from the winning programs produced and contributed by your peers. The
Orthopaedic Research Society. We hope that you spend time Multimedia Education Center is a convenient place to learn by
visiting these poster exhibits and discussing the information with example and to prepare for your future.
the presenters who will be at their display from 12:30 PM until
1:30 PM Wednesday through Friday in the San Diego Convention We are deeply indebted to our program authors. Without their
Center, Sails Pavilion. voluntary contributions of know-how, time, and talent, the
Multimedia Education Center would not be possible.
The Scientific Program Committee is very appreciative of the
effort extended by all the presenters and wishes to congratulate Multimedia programs are group by area of anatomy:
them on the high quality of the abstracts that were submitted for • Award Winners . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 1 – 4
evaluation. • Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Station 5
Poster awards will be presented on Friday morning, February 16, • Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 6 – 9
beginning at 7:00 AM. Awards will be given to the highest rated • Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Station 10
poster in each of the 12 classifications and from them one overall • Shoulder and Elbow . . . . . . . . . . . . . . . . . . . .Stations 11 – 16
winner will be chosen. • Sports Medicine and Arthroscopy . . . . . . . . .Stations 17 – 21
• Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 22 – 25
• Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P001 – P110 • Encore Presentations . . . . . . . . . . . . . . . . . . . .Stations 26 – 30
• Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P111 – P206
• Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . .P207 – P225
• Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . .P226 – P244
• Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P245 – P265
• Practice Management . . . . . . . . . . . . . . . . . . . . . .P266 – P281 POSTERS, SCIENTIFIC EXHIBITS,
• Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . .P282 – P292
• Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . .P293 – P353 AND THE MULTIMEDIA EDUCATION
• Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P354 – P409
• Sports Medicine and Arthroscopy . . . . . . . . . . . .P410 – P460
CENTER ARE LOCATED IN THE
• Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P461 – P526 SAN DIEGO CONVENTION CENTER,
• Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P527 – P552
• Best of ORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P553 – P562 SAILS PAVILION
• Allied Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P563 – P567
• Regional Societies . . . . . . . . . . . . . . . . . . . . . . . . .P568 – P579
POSTER AND SCIENTIFIC EXHIBIT HOURS:
SCIENTIFIC EXHIBITS Wednesday, February 14 – . . . . . . . . . . . 7:00 AM – 6:00 PM
The Scientific Exhibit format is used to graphically illustrate a Friday, February 16
study or a complex procedure. It differentiates itself from a poster Saturday, February 17 . . . . . . . . . . . . . . . 7:00 AM – 5:30 PM
presentation in the amount of material that is presented and uses
audiovisual, interactive demonstration, or some other type of Sunday, February 18 . . . . . . . . . . . . . . . 7:00 AM – 12:30 PM
enhancement in its presentation. The Scientific Exhibits are
located in the Sails Pavilion of the San Diego Convention Center MULTIMEDIA EDUCATION CENTER HOURS:
and open at 7:00 AM, Wednesday through Sunday, to allow you Wednesday, February 14 – . . . . . . . . . . . 7:30 AM – 6:00 PM
to view the exhibits before the scientific program sessions. The Friday, February 16
authors of the exhibits are requested to be present daily between Saturday, February 17 . . . . . . . . . . . . . . . 7:30 AM – 5:30 PM
11:30 AM and 12:30 PM to discuss their ideas and presentation.
The names of the authors presenting the Scientific Exhibits are Sunday, February 18 . . . . . . . . . . . . . . . 7:30 AM – 12:30 PM
printed in boldface.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to page
2 iv. The codes are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full information, refer to
page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 3

HOT TOPICS AND CONTROVERSIES IN

PRIMARY TOTAL HIP ARTHROPLASTY (A)

SYMPOSIA AR HIP
Moderator: Daniel J. Berry, MD, Rochester, MN (a, c - DePuy, a - Zimmer, Stryker)
This symposium will focus on clinically relevant decisions in total hip arthroplasty and will
update surgeons regarding this year’s hip controversies. The format will have 2 or 3
speakers for each topic, each will explain why they favor, prefer or believe in the merits of
one method or approach to a specific problem. To maintain balance and minimize
polarized views, each speaker will give a 5-minute talk; the topic then will be discussed by
the rest of the panel under the guidance of the moderator. The goal will be spirited
discussion but also rational consensus thinking about these controversial but clinically
important topics.

Introduction: Daniel J. Berry, MD (a, c - DePuy, a - Zimmer, Stryker)

I. Operative Approach: Mini Posterior
Mark W. Pagnano, MD, Rochester, MN (c - Zimmer, DePuy)
II. Operative Approach: Mini Anterior
William P. Hozack, MD, Philadelphia, PA (e - Stryker)
III. Operative Approach: Short Conventional
Lester S. Borden, MD, Cleveland, OH (n)
Panel Discussion

IV. Resurfacing Arthroplasty: Time to Consider It Again? Yes

Thomas P. Schmalzried, MD, Los Angeles, CA (a,c,e - DePuy Orthopaedics,
Stryker Orthopaedics, a - Wright Medical Technology, Corin USA)
V. Resurfacing Arthroplasty: Time to Consider It Again? No
Harry E. Rubash, MD, Boston, MA (a, b - Zimmer)
Panel Discussion
VI. Most Recent Data on Bearing Surfaces: Cross-linked PE
William J. Maloney, MD, Stanford, CA (a - DePuy, Medtronics, c - Zimmer, Wright
Medical)
VII. Most Recent Data on Bearing Surfaces: Ceramic-on-Ceramic
William J. Hozack, MD, Philadelphia, PA (e - Stryker)
VIII. Most Recent Data on Bearing Surfaces: Metal-on-Metal
Thomas P. Schmalzried, MD, Los Angeles, CA (a,c,e - DePuy Orthopaedics, Stryker
Orthopaedics, a - Wright Medical Technology, Corin USA)
Panel Discussion
IX. Femoral Fixation in Older Patients: Uncemented
Harry E. Rubash, MD, Boston, MA (a, b - Zimmer)
X. Femoral Fixation in Older Patients: Cemented
Paul F. Lachiewicz, MD, Chapel Hill, NC (a, e - Zimmer)
Panel Discussion
XI. Perioperative Pain Management: Peripheral Nerve Blocks versus Epidurals
Mark W. Pagnano, MD, Rochester, MN (c - Zimmer, DePuy)
XII. Perioperative Pain Management: Pre-emptive Oral Analgesics: Minimizing
Intravenous Narcotics
Jay R. Lieberman, MD, Los Angeles, CA (a,e - DePuy)
Panel Discussion
Case Discussions, Panel Poll and Audience Questions: HO Ossification Prophylaxis,
DVT Prophylaxis; Is there a role for bilateral simultaneous THA?

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
3
SYM 07:Layout 1 1/12/07 11:39 AM Page 4

MINI-POSTERIOR APPROACH FOR THA

Mark W. Pagnano, MD

I. Mini-posterior technique advantages head, particularly when contemporary large diameter

A. Familiar anatomy heads are chosen
B. Widely applicable 18. Formal capsular repair: technique 1 is favored by
C. Predictable (and thus preventable) sources of errors Dorr and involves a soft tissue to soft tissue repair of
SYMPOSIA AR HIP

D. Demonstrated functional advantages over the 2-Incision the posterior capsule and external rotators to the cut
THA in recent prospective randomized trials and in direct edge of the gluteus minimus and edge of the antero-
comparison studies superior capsule. That repair eliminates dead space
postero-superiorly and adds a dynamic stabilizing
II. Familiar anatomy
function as the minimus contracts it pulls the poste-
A. A substantial number of surgeons routinely use the pos-
rior capsule as well. Technique 2 involves formal
terior approach
repair of the capsule and ext rotators to the greater
B. With careful attention to skin incision placement and leg
trochanter through drill holes. When this repair is
positioning intraoperatively it is relatively easy for most
performed it is best to pass the sutures from inside or
surgeons to shorten the skin incision
under the troch such that the capsule is pulled up
C. With the addition of specialized retractors, offset reamers
into the piriformis fossa and not pulled onto the
and offset cup and stem inserters many THA can be done
outer surface of the trochanter.
with a skin incision of 10 cm or less
D. Easily converted to standard posterior approach if intra- IV. Predictable sources of errors
operative concerns arise A. Eccentric acetabular reaming; femur tends to push ream-
E. Formal posterior capsular repair substantially lowers his- er posteriorly; this can result in excessive reaming of pos-
torical risk of dislocation terior wall from the direct pressure; or alternatively exces-
sive reaming of anterior wall if the surgeon moves the
III. Widely applicable
reamer and handle into retroversion to avoid the femur;
A. With relatively little variation this approach can be used
consider offset reamer; modified reamers that are easier
for a broad range of THA patients
to insert
B. Several variations of the mini-posterior technique exist
B. Eccentric reaming from the inferior soft tissues forcing
(Sculco, Dorr, Swanson, Goldstein)
the reamer proximally and into a more vertical position;
C. Dorr technique has been used in my practice and we
consider offset reamer
have studied it extensively in direct comparison studies
C. Cup placement in retroversion and/or excessively vertical
against the 2-Incision technique
(abducted) because of inferior soft tissues and the shaft
1. Lateral decubitus position
of the femur. Consider offset inserter. Use anatomic
2. 8- 10 cm Incision along posterior border of greater
landmarks including: the transverse acetabular ligament
troch extending from the tip of troch to the vastus lat-
as a guide to anteversion; the superior edge of the native
eralis ridge
acetabulum as a guide for abduction.
3. Split gluteus maximus fascia in-line with the muscle
D. Femoral preparation in varus as the view of the proximal
fibers
femur is limited and concerns about the skin edges arise;
4. Hip capsule and external rotators incised off femur
ensure sufficient lateralization of reamers; use specialized
and preserved as one layer
retractors; position an OR light co-linear with the
5. Quadratus attachment distally can often be preserved
femoral canal to see directly down femur
as skill is increased
E. Femoral preparation in retroversion as posterior soft tis-
6. Femoral neck is osteotomized in accordance with
sue bulk and skin edge makes it more difficult to rotate
preop plan measuring neck cut from lesser troch, cen-
broaches into appropriate anteversion; move the leg into
ter of the head, or inferior edge of the femoral head
more extension during this phase ( as opposed to addi-
7. Inferior capsule is incised to level of transverse liga-
tional flexion which one might due in a standard open
ment to relax posterior capsule
posterior approach)
8. Anterior retractor moves femur anterior to socket
F. Small amounts of bleeding can substantially limit visual-
9. Inferior retractor at level of transverse ligament
ization: consider doing most of initial exposure with
10. Posterior retractor can be placed along posterior col-
cautery and control even small bleeding right from the
umn
start of the operation
11. Transverse ligament used as a guide to anteversion
12. Reaming socket begins with reamer 2mm smaller V. Direct Comparison Data Mini-posterior versus 2-Incision
than templated size; offset reamer helpful THA
13. Real socket placed. A. Mardones R, Pagnano MW, Nemanich JP, Trousdale RT. The
14. Femur is exposed with specialized retractors; care Hip Society Frank Stinchfield Award: Muscle damage after
used to protect skin; many times inserting broaches total hip arthroplasty done with the two-incision, mini-posteri-
initially in marked retroversion will allow clearance or techniques. CORR December, 2005.
of skin edge; then rotate into appropriate anteversion 1. Cadaveric study clearly demonstrated that it was not
prior to impaction possible to do 2-incision THA without substantial
15. Trial reduction; stability check damage to the abductors, the external rotators or both
16. Real femoral insertion 2. The extent of damage to the abductors was significant-
17. Real head chosen and inserted; most often all retrac- ly greater with the 2-incision technique than with
tors must be taken out to facilitate insertion of the mini-posterior technique
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
4 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 5

B. Pagnano MW, Meneghini RM, Trousdale RT, Hanssen: 2. Randomized with a computer program to ensure
Patients preferred a mini-posterior THA over a contralateral dynamic balancing of the 2 groups with respect to
two incision total hip. CORR November 2006. age, sex and BMI
1. 26 patients had staged bilateral THA with a 2-incision 3. Early functional results based on functional mile-
THA on one side and a mini posterior THA on the stones
other 4. Mini-posterior hips quicker to return to ADL, get rid
2. Six months after the second THA was done patients of crutches and get rid of a cane. In no parameter was
were asked to compare the early functional result and 2-incision quicker.
state a preference for one hip or the other D. Pagnano MW, Meneghini RM, Kaufmann K et al: A

SYMPOSIA AR HIP
3. Most patients preferred the mini-posterior hip and the Prospective Randomized Gait Analysis study Shows No Benefit
stated it was because of better early recovery of 2-Incision THA over mini-posterior THA. AAOS 2007.
C. Pagnano MW, Meneghini RM, Leone J: A Prospective 1. 20 patients with primary degenerative arthritis of the
Randomized Trial Shows that 2-Incision Hips Recover more hip
Slowly than Mini-posterior Hips. AAOS 2007; Dorr Award 2. Preop comprehensive gait analysis including level
Paper AAHKS 2006. walking and stair climbing
1. 72 patients with primary degenerative arthritis of the 3. Postop comprehensive gait analysis at 8 weeks
hip

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
5
SYM 07:Layout 1 1/12/07 11:39 AM Page 6

OPERATIVE APPROACH – MINI ANTERIOR

William Hozack, M.D.

My approach to THA is to make one incision as small as possi- approach, proper instrumentation is very important in mini-
ble but as large as necessary, to obtain direct visualization of the mizing the soft tissue damage and a prosthesis designed specif-
bony anatomy and to use modified instrumentation in order to ically for the approach facilitates the procedure.
minimize soft tissue trauma. I use the both the direct anterior
A cadaver study was performed to evaluate muscle damage with
SYMPOSIA AR HIP

(modified Smith Peterson) and MIS direct lateral approach

the DA approach as compared to a mini-posterior approach. In
selectively in my practice. The direct anterior (DA) approach
six cadavers operated with both approaches, the DA approach
goes between muscle intervals and, more importantly, between
resulted in significantly less damage to the abductor mecha-
nerve innervations. The AL approach cuts a muscle insertion but
nism. The price was more damage in the anterior muscles – TFL,
this may actually reduce overall muscle trauma. The lateral
rectus femoris. It is quite clear that all MIS approaches damage
femoral cutaneous nerve is at risk in the traditional DA
soft tissue to some extent.
approaches, but a more lateral incision virtually eliminates this
problem. During a learning curve of the DA approach I learned A recent prospective study is ongoing evaluating the DA and
several things. Obese patients (BMI > 30) can be done through direct lateral approaches. In this study the pain management
the DA approach, but the minimally invasive character of the protocols, anesthesia, patient selection criteria, surgeon, and
operation may be compromised. Patients with poor bone qual- physical therapy regimens were identical between the groups.
ity and significant abnormalities of the bony anatomy make the The preliminary results do suggest faster recovery and better
operation through a DA approach more difficult. For each function in the DA group.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
6 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 7

OPERATIVE APPROACH: SHORT CONVENTIONAL INCISION: A

REASONABLE COMPROMISE
Lester S. Borden, MD

The goals of total hip arthroplasty are to provide a reproducible er incisions should always be extensile thereby allowing greater
operation with minimal complications resulting in a well func- exposure intraoperatively when needed.

SYMPOSIA AR HIP
tioning, painless, and durable joint. Although contemporary
Proponents of minimally invasive surgical exposure claim less
prosthetic components and materials have greatly reduced the
blood loss, less postoperative pain, shorter hospitalization, less
likelihood of loosening and osteolysis, good surgical technique
rehabilitation time and better cosmesis than can be achieved
remains essential in avoiding tissue damage, allowing proper
with conventional incisions. Unfortunately, marketing efforts
component implantation and reducing intraoperative and post-
through the internet and media have placed unnecessary pres-
operative complications.
sure on surgeons to respond to these claims. There are multiple
Today, it is generally accepted that routine total hip arthroplas- publications indicating that complications are not only more
ty can be safely performed through shorter conventional inci- frequent but more serious with minimal incisions (nerve dam-
sions than were used in the past. We have learned that less mus- age, femoral fractures, dislocations, infections). Shorter conven-
cle dissection and retraction are required to achieve good visu- tional incisions are a reasonable compromise that can avoid
alization of the joint and ample access to both the femur and these problems.
acetabulum than wider exposures used in the past. These short-

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
7
SYM 07:Layout 1 1/12/07 11:39 AM Page 8

RESURFACING ARTHROPLASTY: TIME TO CONSIDER IT AGAIN?

YES
Thomas P. Schmalzried, M.D.

When mated to a conventional polyethylene acetabular compo- operation is initially “conservative” on both the femoral and
nent, the large diameter of resurfacing components (38-54mm) acetabular sides. If the wear of the bearing is as low as expect-
SYMPOSIA AR HIP

results in a volumetric wear that is 4-10 times higher than that ed, periprosthetic osteolysis is also likely to be low.
of a 28mm bearing couple. This resulted in very high osteolysis
The risk of femoral-side failure of metal-metal surface replace-
and loosening rates in the resurfacing experience of the late
ment (MMSR) has been associated with female gender, a
1970’s and early 1980’s – often associated with extensive acetab-
femoral head cyst >1cm, shorter patients, smaller component
ular bone loss – thus violating the “conservative” premise of the
size (in males), relative varus positioning and extensive ose-
operation.
tonecrosis. Beaule et al. have developed a surface arthroplasty
Consistently low wear of MM bearings has been established by risk index (SARI). Two points are given for femoral head cysts
over 30 years of clinical experience. Metal-metal bearings do not of >1 cm; 2 points for a weight of <82 kg; 1 point for previous
fracture. Metal-metal bearings favor a larger diameter: the wear surgery; and 1 point for a UCLA activity level of >=7. For
rate of a metal-metal bearing decreases with increasing diame- patients with a SARI of >3, the rate of survival of the arthroplas-
ter. Lubrication of a metal-metal joint is a function of sliding ty at four years was 89% compared with a rate of 97% for those
velocity. The larger the diameter, the higher the sliding velocity with a score of <=3.
and the better the lubrication. The risk of cancer associated with
High survivorship was seen in large males. There is higher sur-
a metal-metal bearing is no greater than that associated with a
vival with denser bone and larger fixation area and emphasize
metal-polyethylene bearing. With more than 30 years of clini-
the importance of patient selection and surgical technique.
cal use, a health risk due to elevated cobalt and chromium ions
Resurfaced hips can reliably be lengthened up to 1cm. Femoral
in patients with a metal-metal bearing has not been established.
off-set following resurfacing was essentially equal to that of the
This needs to be compared to the fact that the 90 day mortality
same hip pre-operatively but was less than the off-set of the nor-
following revision total hip replacement surgery in the Medicare
mal, contralateral hip. These results indicate that femoral mor-
population is 2.6%. There may be an increased risk of devel-
phology should be considered in the selection of patients for
oping delayed-type hypersensitivity (an allergic reaction) with a
MMSR and that those with a relatively low off-set may be better
metal-metal bearing. Cobalt and chromium based implants
served by a conventional total hip.
should not be used in patients with a clear history of metal sen-
sitivity, such as a consistent allergic reaction to jewelry. A metal-
There are 4 parameters to consider in the selection of hips for
metal bearing should be avoided in patients with abnormal
resurfacing: 1) shape (head:neck > 1.2; neck length > 2 cm); 2)
renal function.
good bone density; 3) no focal bone defects >1cm; 4) favorable
Considering the durable fixation of press-fit cementless hemi- biomechanics (good off-set; >120° valgus; limb length within
spherical acetabular components, it is reasonable to consider 1cm). These criteria lead to a practical grading system: Grade A
combining a femoral resurfacing shell with a modern design = “normal hip; no cartilage”; Grade B = lacks 1 factor; Grade C
cementless cobalt chromium acetabular component. The thick- = lacks 2 factors; Grade D = lacks 3 factors. The outcomes of
ness of the walls of this acetabular component can be <4mm. total hip resurfacing are better with higher grade hips.
In this case, acetabular reaming for the surface replacement is no
greater than for a conventional total hip component. Thus, the

REFERENCES 5. Hallab, N., Merritt, K., Jacobs, J.J: Metal sensitivity in patients with orthopaedic
1. Schmalzried, T.P.; Peters, P.C.; Maurer, B.T.; Bragdon, C.R., and Harris W.H.: implants. J. Bone Joint Surg. 83-A: 428-436, 2001.
Long duration metal-on-metal total hip replacements with low wear of the artic- 6. Beaule P. et al.: Risk factors affecting early outcome of metal on metal surface
ulating surfaces. J. Arthroplasty, 11:322-331, 1996. arthroplasty of the hip in patients 40 years old and younger. Clin Orthop
2. Schmalzried, T.P.; Szuszczewicz, E.S.; Akizuki, K.H.; Petersen, T.D., and Amstutz, 418:80-87, 2004.
H.C..: Factors correlating with long-term survival of McKee-Farrar total hip pros-
theses. Clin. Orthop. 329S:S48-S59, 1996. 7. Amstutz, H.C. et al.: Metal-on-metal hybrid surface arthroplasty: Two to six-year
follow-up study. J. Bone Joint Surg. 86-A: 28-39, 2004.
3. Tharani, R. Dorey, F. J. and Schmalzried, T.P.: The risk of cancer following total
hip or total knee replacement. J. Bone and Joint Surg. 83-A:774-780, 2001. 8. Silva, M. et al.: The biomechanical results of total hip resurfacing arthroplasty. J.
Bone Joint Surg. 86-A:40-46, 2004.
4. Mahomed, N. N. et al.: Rates and outcomes of primary and revision total hip
replacement in the united states medicare population. J. Bone Joint Surg. 85- 9. Schmalzried, T.P.; Silva, M.; de la Rosa, M.; Choi, E.S. and Fowble, V.A. :
A:27-32, 2003. Optimizing patient selection and outcomes with total hip resurfacing. Clin.
Orthop. 441:200-204, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
8 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 9

RESURFACING ARTHROPLASTY: TIME TO CONSIDER IT AGAIN?

NO
Harry E. Rubash, MD, Boston, MA

Innovation and change are vital to the advancement of the field rence of pain, joint effusions, and the formation of radiolucent
of orthopaedic surgery. Total hip arthroplasty (THA) is one of lines around the implant, has been demonstrated. 15 The level

SYMPOSIA AR HIP
the most successful operations in orthopaedics. Therefore, a of lymphocyte reactivity has also been shown to increase lin-
novel procedure designed to replace THA, even for select indi- early with respect to the level of metal ions. 4 Even if a metal on
cations, should be more than different, it should provide a def- metal THA is selected, the patient’s exposure to ions is lower
inite improvement over a well-established gold standard. Hip than after a hip resurfacing arthroplasty, likely due to a smaller
resurfacing arthroplasty does not meet this standard. diameter bearing surface.1 Therefore, even if choosing a metal
on metal bearing THA, the incidence of negative effects due to
Despite the outstanding performance of THA, hip resurfacing
ions may be lower than with a hip resurfacing arthroplasty. THA
arthroplasty has been advocated for younger patients, due to the
also offers the opportunity to use alternative bearing surfaces to
historically inferior survival of THA in this population. 2
metal on metal, with good results in younger patients. 12 In
However, more recently, the results of THA in young patients
summary, although the long-term impact of metal ion release in
have shown improved survival with the advent of new surgical
vivo is unknown, concerns regarding carcinogenesis, hypersen-
techniques, implant designs, and alternative bearing surfaces.
sitivity reactions (ALVAL), renal and liver toxicity, and other bio-
Eskelinen et al. reported on the results of 4,661 THAs in patients
logical effects remain, making this an important consideration
under age 55 from the Finnish Registry who had been treated
for patients and surgeons.
with circumferentially proximally porous-coated uncemented
stems, and found a 10-year survival rate of 99% with aseptic Clearly, femoral neck bone stock is preserved in hip resurfacing,
loosening as the endpoint. 3 Kearns et al reported on the results when compared with THA. However, the impact on future revi-
of 221 uncemented THAs in patients under age 50 and demon- sion surgery is unknown. To date, there are no studies demon-
strated femoral stem survival of 99.3%, 98.9% and 96.8% at 5, strating that revisions of hip resurfacing arthroplasties are tech-
10 and 15 years. 6 McAuley et al. reviewed the results of 561 nically easier or that they have improved outcomes compared
extensively porous-coated THAs in patients under age 50, and with revisions of primary THAs. This fact should be considered
showed a 10-year survival of 89% of both femoral and acetabu- carefully in light of the poorer survival of hip resurfacing arthro-
lar components. 9 These results demonstrate that THA can be a plasty. Furthermore, an analysis by Loughead et al. found that
very durable procedure, even in a young patient population. a larger cup size is needed for hip resurfacing arthroplasty to
accommodate the femoral prosthesis when compared with con-
Furthermore, in head to head comparisons, the survival of THA
ventional THA, which results in increased removal of acetabular
has been superior to hip resurfacing arthroplasty. Mont et al.
bone stock. 8 This could compromise the results of future revi-
evaluated 30 matched pairs of patients with avascular necrosis
sion procedures for hip resurfacing arthroplasties, and suggests
treated with THA and hip resurfacing arthroplasty, and found a
that hip resurfacing arthroplasty overall may be a bone deplet-
93% survival of the THAs, with only a 90% survival of the hip
ing, rather than a bone conserving procedure, on the acetabular
resurfacing arthroplasties at seven years. 11 The Australian
side. Furthermore, the acetabular component of a hip resurfac-
Registry, which contains data on over 4,900 hip resurfacing
ing arthroplasty is non-modular and can only accommodate a
arthroplasty procedures, has also shown superior short-term
very specific femoral implant. If a well-fixed hip resurfacing
survival for THAs over hip resurfacing arthroplasty.5
acetabular component must be removed to accommodate the
Patients undergoing a hip resurfacing arthroplasty also incur needs of femoral revision due to this lack of modularity, acetab-
risks, which differ from those incurred with a THA. As a new ular bone stock may be further compromised.
procedure, hip resurfacing arthroplasty may be associated with
An additional argument for hip resurfacing arthroplasty has
a significant learning curve for surgeons, negatively impacting
been the suggestion that it is associated with improved func-
their early results. 10 The larger exposure may increase the risk
tional outcomes. THA has been one of the most successful
for nerve palsy, vascular injury or infection, and may lead to
operations in orthopaedics in improving patient function.
poorer cosmesis, which could impact patient satisfaction. A sig-
Patients have demonstrated that these improvements are of
nificant risk of femoral neck fracture also exists. This complica-
great value to them, assigning the procedure an average utility
tion is unique to hip resurfacing, when compared with THA.
value of 0.9 (Scale 0-1). 7 Select studies have suggested hip
Mont et al. reported a 22% fracture rate in a series of the first
resurfacing arthroplasty patients have higher activity levels than
fifty hip resurfacing arthroplasties, with a 2% rate in the next
THA patients post-operatively.14 However, studies examining
fifty cases,10 implying a significant learning curve may exist.
the functional outcomes of hip resurfacing arthroplasty have
Shimmin et al, reported the findings of an Australian Registry
been plagued by patient selection issues, lack of randomization
study, which demonstrated an overall incidence of femoral neck
and lack of blinded assessment, making it impossible at this
fracture of 1.46%, with no evidence for a relationship between
time to attribute any differences found directly to the specific
surgeon experience and the risk of fracture, suggesting the inci-
procedure. No randomized clinical trial comparing the func-
dence of this complication may persist over time.13
tional results of these two procedures has been published, and
Current hip resurfacing arthroplasty implants require the use of these trials are needed to establish superior outcomes of either
a metal on metal bearing surface, which has been shown to gen- procedure.
erate cobalt and chromium ions in vivo. A lymphocyte-domi-
In conclusion, THA is a proven durable procedure with excellent
nated immunological response in patients with metal on metal
results and superior short-term survival to hip resurfacing
bearing arthroplasties, which leads to persistent or early recur-
arthroplasty. The unique risks of hip resurfacing arthroplasty,
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
9
SYM 07:Layout 1 1/12/07 11:39 AM Page 10

including the steep learning curve, technical difficulty, and the THA should remain the gold standard and reconsideration of
risk of femoral neck fracture, in addition to the concerns for hip resurfacing arthroplasty is unwarranted at this time, until
metal ion effects, the potential revision challenges, and the lack appropriate comparative studies can demonstrate a clear bene-
of literature support for superior functional outcomes, make the fit to patients.
expected results less reliable than the results of THA. Therefore,
SYMPOSIA AR HIP

REFERENCES 8. Loughead, J. M.; Starks, I.; Chesney, D.; Matthews, J. N.; McCaskie, A. W.; and
1. Clarke, M. T.; Lee, P. T.; Arora, A.; and Villar, R. N.: Levels of metal ions after Holland, J. P.: Removal of acetabular bone in resurfacing arthroplasty of the hip: a
small- and large-diameter metal-on-metal hip arthroplasty. J Bone Joint Surg Br, comparison with hybrid total hip arthroplasty. J Bone Joint Surg Br, 88(1): 31-4,
85(6): 913-7, 2003. 2006.

2. Dorr, L. D.; Luckett, M.; and Conaty, J. P.: Total hip arthroplasties in patients 9. McAuley, J. P.; Szuszczewicz, E. S.; Young, A.; and Engh, C. A., Sr.: Total hip
younger than 45 years. A nine- to ten-year follow-up study. Clin Orthop Relat arthroplasty in patients 50 years and younger. Clin Orthop Relat Res, (418): 119-
Res, (260): 215-9, 1990. 25, 2004.

3. Eskelinen, A.; Remes, V.; Helenius, I.; Pulkkinen, P.; Nevalainen, J.; and 10. Mont, M. A.; Ragland, P. S.; Etienne, G.; Seyler, T. M.; and Schmalzried, T. P.: Hip
Paavolainen, P.: Total hip arthroplasty for primary osteoarthrosis in younger resurfacing arthroplasty. J Am Acad Orthop Surg, 14(8): 454-63, 2006.
patients in the Finnish arthroplasty register. 4,661 primary replacements followed 11. Mont, M. A.; Rajadhyaksha, A. D.; and Hungerford, D. S.: Outcomes of limited
for 0-22 years. Acta Orthop, 76(1): 28-41, 2005. femoral resurfacing arthroplasty compared with total hip arthroplasty for
4. Hallab, N. J.; Anderson, S.; Caicedo, M.; Skipor, A.; Campbell, P.; and Jacobs, J. J.: osteonecrosis of the femoral head. J Arthroplasty, 16(8 Suppl 1): 134-9, 2001.
Immune responses correlate with serum-metal in metal-on-metal hip arthroplas- 12. Murphy, S. B.; Ecker, T. M.; and Tannast, M.: Two- to 9-Year Clinical Results of
ty. J Arthroplasty, 19(8 Suppl 3): 88-93, 2004. Alumina Ceramic-on-Ceramic THA. Clin Orthop Relat Res, 2006.
5. http://www.dmac.adelaide.edu.au/aoanjrr/publications.jsp. 13. Shimmin, A. J., and Back, D.: Femoral neck fractures following Birmingham hip
6. Kearns, S. R.; Jamal, B.; Rorabeck, C. H.; and Bourne, R. B.: Factors Affecting resurfacing: a national review of 50 cases. J Bone Joint Surg Br, 87(4): 463-4, 2005.
Survival of Uncemented Total Hip Arthroplasty in Patients 50 Years or Younger. 14. Vail, T. P.; Mina, C. A.; Yergler, J. D.; and Pietrobon, R.: Metal-on-Metal Hip
Clin Orthop Relat Res, 2006. Resurfacing Compares Favorably with THA at 2 Years Followup. Clin Orthop
7. Laupacis, A.; Bourne, R.; Rorabeck, C.; Feeny, D.; Wong, C.; Tugwell, P.; Leslie, K.; Relat Res, 2006.
and Bullas, R.: The effect of elective total hip replacement on health-related qual- 15. Willert, H. G.; Buchhorn, G. H.; Fayyazi, A.; Flury, R.; Windler, M.; Koster, G.; and
ity of life. J Bone Joint Surg Am, 75(11): 1619-26, 1993. Lohmann, C. H.: Metal-on-metal bearings and hypersensitivity in patients with
artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg
Am, 87(1): 28-36, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
10 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 11

MOST RECENT DATA ON BEARING SURFACES: CROSS-LINKED PE

William J. Maloney, MD

Highly crosslinked polyethylene has now been in wide-spread would have fractured in either situation. The net result is that
use for more than five-years. Essentially all major manufactur- some of the elevated rim liners are no longer available espe-
ers now have some form of highly crosslinked polyethylene cially in the small sizes where the polyethylene can be thin at
which is marketed and sold in the United States. These prod- the rim of the acetabulum. This should eliminate or mini-

SYMPOSIA AR HIP
ucts have for the most part replaced conventional polyethylene mize the problem. In addition, it’s important for the surgeon
and to some extent, conventional polyethylene is now obsolete. to note that the solution for a malpositioned socket with an
unstable hip is not an elevated rim liner with a large femoral
There are several ongoing trials both prospective trials and ran-
head. Malpositioned sockets that are significantly vertical
domized prospective trials evaluating highly crosslinked poly-
should be changed if possible.
ethylene and comparing it to conventional polyethylene.
Clinically, the studies that have been reported to-date including
2. Bioreactivity of the Highly Crosslinked Material:
the studies utilizing larger femoral heads, have demonstrated
There has been some controversy in the literature as it relates
that the highly crosslinked material has behaved as predicted by
to the biologic reactivity and the osteolytic potential of wear
the in-vitro wear testing. In the first year following joint replace-
debris from highly crosslinked polyethylene compared to
ment, there tends to be a “bedding in” phase in which the
conventional polyethylene. This is a difficult issue to sort
femoral head penetration into the acetabular polyethylene is
out. However when one thinks about the biologic potential
second to polyethylene creep. This is similar with both con-
of the two bearing surfaces, it’s clear that highly crosslinked
ventional and highly crosslinked material. After one year, the
material wins out. Even if the crosslinked material on a par-
femoral head penetration rates with the highly crosslinked
ticle by particle basis is more reactive because of the size
material tends to go towards a zero wear rate. In contrast, con-
range, the overall load of particles is much smaller with the
ventional polyethylene tends to wear at the historically reported
highly crosslinked material. Therefore, the biologic potential
rate and is denoted by a femoral head penetration of approxi-
as it relates to the production of osteolysis will be less over-
mately 0.1 mm per year. To my knowledge, there has been no
all. That is obviously the important issue from the patient
reported cases of runaway polyethylene wear or severe early
and surgeon standpoint.
osteolysis with the highly crosslinked polyethylene materials
despite the manufacturer.
3. In Vivo Oxidation:
It is important to note that there are some subtle and some not The majority of the products on the market have manufac-
so subtle differences between manufacturers’ processes and each tured the polyethylene inserts in such as way as to eliminate
product must be evaluated independently. Because a problem or minimize free radicals. This in turn minimizes or elimi-
occurs with one specific product, that problem may or may not nates the potential for in vivo oxidation. Free radicals that
be applicable to the group of highly crosslinked polyethylenes are left in the material can oxidize in the body and poten-
as a whole. tially have consequences as it relates to wear several years
after implantation. In one product, this is a potential issue
There have been some specific issues that have been identified
and the manufacturer has introduced a new product that
and either addressed or studied and determined not be a signif-
appears to have eliminated that issue. It’s important to note
icant clinical issue. Those include:
that although it has been a theoretical issue and there has
been some retrievals demonstrating a white band formation,
1. Mechanical Properties:
it has not been a demonstrated issue as it relates to wear or
It’s clear that compared to conventional polyethylene that
clinical performance.
some mechanical properties such as the fatigue strength of
the material as well as the elongation to failure are dimin- Over the first five-years, the highly crosslinked polyethylene
ished when compared to conventional polyethylene. materials have performed extremely well. Femoral head pene-
However it’s very important to remember that in all the prod- tration which is measured radiographically and is a surrogate
ucts, these values still exceed ASTM standards. There have for wear has been very low and in general has been in the range
been some acetabular liners that have broken and this has predicted by the hip simulator studies. If the material continues
been studied. In each case, it was a clinical situation in which to perform as well as over the next five-years, we should achieve
the acetabular component was malpositioned. The liners our goal of reduction in periprosthetic osteolysis and implant
utilized were elevated rim liners and a large femoral head was loosening which in turn should equate to a reduction in re-
subluxing or resting on unsupported polyethylene. Finite operation. That is obviously the important issue from the
element studies have demonstrated that whether the materi- patient standpoint.
al was conventional or highly crosslinked polyethylene, it

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
11
SYM 07:Layout 1 1/12/07 11:39 AM Page 12

CERAMIC ON CERAMIC BEARINGS

William Hozack, M.D.

I. The main benefit of COC bearings is related to reduced d. Noise

wear, to the point where the ceramic may not wear out in i. Noises are created with all bearings
your lifetime. ii. Clicking is the most common symptom reported
a. Extreme hardness leading to scratch resistant, especially iii. MOM squeaking
SYMPOSIA AR HIP

in the presence of third body particles such as bone 1. Back JBJS 2005 reported a 3.9% incidence
debris or cement 2. Squeaking with MOM seems to happen early
b. Low co-efficient of friction related to small grain size and 3. Self polishing of the metal bearing occurs and then
low surface roughness. the incidence of squeaking appears to decrease
c. Maintenance of low surface roughness over time because iv. COC squeaking
of resistance to third body wear and oxidation 1. Impingement appears to be central to the cause,
d. Better wettability leading to better lubrication properties but other factors play a role
2. Company reported incidence is <1%, but higher
II. Two other possible benefits of COC bearings
incidence has been seen by individual surgeons
a. Reduced reactivity of the particles within the body tis-
and centers
sues.
3. Squeaking with COC appear after 1 year
i. Lerouge JBJS 1997, Catelas JBJS 1999
4. No evidence at this time that squeaking adversely
b. No systemic release of ions in the body
affects longevity or wear
i. Titanium ions may be released from the interface of
v. How to deal with squeaking:
the femoral head with the femoral component
1. Preoperatively inform patients of the possibility
trunion
2. Encourage patience when it develops as it may dis-
III. Updates on ceramic on ceramic bearings appear with time (especially with MOM)
a. Cost 3. Synvisc injections?
i. Newer materials being developed for other bearings 4. Revision to polyethylene bearing
will close the gap – resurfacing arthroplasty is consid-
IV. Surgical Pearls
erably more expensive
a. Thoroughly evaluate range of motion and impingement
b. Ceramic fracture
with trials during surgery
i. Estimated risk of fracture is 0.014% (1 in 7000)
i. Optimize component placement (particularly on the
ii. All ceramic components are proof-tested for burst
acetabular side) to minimize impingement
strength prior to shipping
ii. CAS systems may be beneficial
iii. New Delta ceramics are even tougher
b. Femoral head selection
iv. When a fracture occurs, rapid revision is imperative to
i. Use only with design specific femoral component
minimize damage to the femoral component trunion,
ii. Place on clean dry trunion free of debris
thus simplifying revision surgery
iii. Fully seat before impaction
v. A new ceramic bearing should be considered since
c. Femoral component selection to minimize impingement
any residual ceramic debris left after revision will seri-
i. Choose components with reduced neck diameters
ously compromise the longevity of softer bearings
ii. Choose components with variable offset
(polyethylene in particular – Alain JBJS 2003)
iii. Choose components with proportionate neck length
vi. A titanium sleeve should be placed on the damaged
to size
trunion if possible to reduce fracture risk in the new
ceramic ball (Sharkey ORS 2004)
c. Fewer intra-operative choices – no longer the case
i. Not reflected in higher dislocation rates
ii. Only a zero degree liner is available
iii. Delta ceramic heads offer more than adequate neck
lengths

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
12 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 13

METAL-METAL BEARINGS
Thomas P. Schmalzried, M.D.

Consistently low wear of MM bearings has been established by pared to the fact that the 90 day mortality following revision
over 30 years of clinical experience. Not just laboratory wear total hip replacement surgery in the Medicare population is
simulations. Real experience in real patients, many under 60 2.6%!
years of age at the time of surgery.
There may be an increased risk of developing delayed-type

SYMPOSIA AR HIP
Metal-metal bearings favor a larger diameter: the wear rate of a hypersensitivity (an allergic reaction) with a metal-metal bear-
metal-metal bearing decreases with increasing diameter and ing. Cobalt and chromium based implants should not be used
favors hip resurfacing. Lubrication of a metal-metal joint is a in patients with a clear history of metal sensitivity, such as a con-
function of sliding velocity. The larger the diameter, the higher sistent allergic reaction to jewelry. A metal-metal bearing should
the sliding velocity and the better the lubrication. only be used in patients with normal renal function.
The risk of cancer associated with a metal-metal bearing is no There is substantial patient-to-patient variability in serum ion
greater than that associated with a metal-polyethylene bearing. levels. After the run-in period, serum ion levels are not directly
Despite more than 30 years of clinical use, a health risk due to a function of patient activity.
elevated cobalt and chromium ions in patients with a metal-
metal bearing has not been established. This needs to be com-

REFERENCES 4. Mahomed, N. N. et al.: Rates and outcomes of primary and revision total hip
1. Schmalzried, T.P.; Peters, P.C.; Maurer, B.T.; Bragdon, C.R., and Harris W.H.: replacement in the united states medicare population. J. Bone Joint Surg. 85-
Long duration metal-on-metal total hip replacements with low wear of the artic- A:27-32, 2003.
ulating surfaces. J. Arthroplasty, 11:322-331, 1996. 5. Hallab, N., Merritt, K., Jacobs, J.J: Metal sensitivity in patients with orthopaedic
2. Schmalzried, T.P.; Szuszczewicz, E.S.; Akizuki, K.H.; Petersen, T.D., and Amstutz, implants. J. Bone Joint Surg. 83-A: 428-436, 2001.
H.C..: Factors correlating with long-term survival of McKee-Farrar total hip pros- 6. Heisel, C. et al.: The relationship between activity and ions in patients with
theses. Clin. Orthop. 329S:S48-S59, 1996. metal-on-metal bearing hip prostheses. J. Bone Joint Surg. 87-A:781-787, 2005.
3. Tharani, R. Dorey, F. J. and Schmalzried, T.P.: The risk of cancer following total
hip or total knee replacement. J. Bone and Joint Surg. 83-A:774-780, 2001.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
13
SYM 07:Layout 1 1/12/07 11:39 AM Page 14

FEMORAL FIXATION IN OLDER PATIENTS: UNCEMENTED

Harry Rubash, MD, Boston, MA

Total hip arthroplasty (THA) is a successful operation providing the use of cemented femoral implants7. This is primarily due to
patients with an exceptional quality of life1. The femoral com- the extra equipment required for current cementing techniques
ponent may be cemented or uncemented. Uncemented femoral and to the extended operative time required for cementing. The
stems are proximally or fully coated to provide biological fixa- improved cost-effectiveness of cementless hip arthroplasty is
SYMPOSIA AR HIP

tion. Despite similar long-term results, uncemented femoral fix- important with the increasing number of patients undergoing
ation possesses additional benefits including decreased mor- this procedure in an era of declining healthcare resources.
bidity and improved cost-effectiveness. Thus, the authors feel
Uncemented femoral stems provide the necessary modularity
that uncemented femoral implants for total hip arthroplasty is
and geometry for fixation in most types of femoral canals. For
an excellent choice in the elderly patient population.
example, the diversity of stem options allowed Keisu et al. to use
The biological fixation provided by uncemented stems has led uncemented stems resulting in no femoral revisions at 2-11
to excellent long-term survival, an important feature even in eld- years, these included patients with Dorr type C bone morphol-
erly patients, who are likely to live for many years after their hip ogy8. The expanded modularity for the cementless femoral
replacement. Marshall et al noted a 1.5% femoral revision rate component can be valuable for equalizing leg lengths, for
for a proximally coated, tapered stem in 200 hips at 10-15 obtaining enhanced stability, and for securing optimum fixa-
years2. Parvizi et al. revised only 1 uncemented, proximally tion in primary and revision hip arthroplasty9.
coated femoral stem from a series of 129 hips at an average fol-
The use of cement for femoral fixation has several disadvantages
low-up 11 years3. Bourne et al. had no revisions of proximally
in the elderly. There is an increased morbidity in all patients
coated, tapered femoral stems for aseptic loosening in 307 hips
from cement-related hypotension, fat embolism and increased
at 10-13 year follow-up4. These studies demonstrate that the
operative time associated with the use of cement10. These effects
survival of uncemented femoral components is outstanding and
can be particularly problematic in elderly patients with under-
is comparable to the results of cemented femoral implants.
lying cardiac or pulmonary pathology. Pitto et al noted that
Cemented stems have traditionally been advocated for elderly there is a 0.06% rate of intra-operative mortality that may be
patients because of the low incidence of thigh pain and intra- associated to cement-related pulmonary embolism11. The abil-
operative fractures in osteopenic bone. Bourne et al. assessed ity to reduce the risks of surgery in a patient population where
283 patients who underwent cementless THA with a proximal- the peri-operative complication rate with total hip arthroplasty
ly coated, tapered stem and noted only 3% of patients had mild is approximately 24% is a valuable advantage of the uncement-
to moderate activity-related thigh pain4. On the other hand, ed technique8.
uncemented stems have been used more frequently in younger
A second disadvantage of cement fixation is the difficulty
patients because of improved load sharing with native bone,
encountered in revision surgery. Removing the cement mantle
increased modularity, and excellent biological fixation allowing
of a femoral stem is challenging and time consuming12.
for high activity levels.
Removal may necessitate bone damage due to the need for pro-
In today’s society, being elderly does not equate with being inac- cedures such as the extended trochanteric osteotomy, or the for-
tive. THA patients have an increasing life expectancy. mation of cortical windows for cement removal. The use of spe-
Chronological age does not necessarily correlate with physio- cialized instruments to remove cement also carry inherent risks,
logical age or activity level, and patients often remain active for including femoral perforation, thermal tissue damage with the
many years. These factors should be taken into consideration for use of an ultrasonic device, and increased infection risk second-
clinical decision-making when choosing an implant for a par- ary to contaminated aerosols from a burr device13, 14. The
ticular patient5. Therefore, the use of uncemented femoral extrication of a failed uncemented femoral stem is not as fre-
implants should be contemplated for hip arthroplasty in all quently associated with these complications15. Furthermore,
patients. the preserved bone stock created by load sharing can be valuable
in the revision setting.
The preservation of femoral bone stock is desirable in elderly
patients with osteoporosis. The variety of stem geometries and In conclusion, uncemented implants have become the gold
surface coatings with cementless femoral stems allow biological standard for THA in the young, and have now been shown to
fixation in a variety of femoral canal geometries. Proximal stem have excellent survivorship in the elderly with all bone mor-
fixation physiologically loads the proximal femur to minimize phology. The advantages of uncemented implants include bio-
bone loss secondary to stress shielding6. This is important in logical implant fixation, physiological loading of the bone,
elderly patients with pre-operative osteopenia. decreased morbidity from pulmonary embolism, superior mod-
ularity, improved cost effectiveness and easier removal during
Another societal advantage to uncemented THA is improved cost-
revision. These properties establish cementless femoral fixation
effectiveness. Barrack et al. found that cementless femoral stem
as the ideal choice for the elderly patient.
usage for hip arthroplasty was approximately 8% less costly than

REFERENCES 3. Pavizi J, Keisu KS, Hozack WJ, Sharkey PF, Rothman RH. Primary total hip
1. Bozic KJ, Saleh KJ, Rosenberg AG, Rubash HE. Economic evaluation in total hip arthroplasty with an uncemented femoral component. J Arthroplasty 2004.
arthroplasty: Analysis and review of the literature. J Arthroplasty. 2004. 19(2): 19(2): 151-156.
180- 189. 4. Bourne RB, Rorabeck CH, Patterson JJ, Guerin J. Tapered titanium cementless
2. Marshall AD, Mokris JG, Reitman RD, Dandar A, Mauerhan DR. Cementless tita- total hip replacements: a 10 to 13 year follow-up. Clin Orthop Rel Res. 2001.
nium tapered-wedge femoral stem: 10-15 year follw-up. J Arthroplasty. 2004. 393: 112-120.
19(5): 546- 552.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
14 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 15

5. Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effective- 11. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral compo-
ness analysis to evealuate new technologies in orthopaedics: the case of alterna- nent without cement and fixation with use of a bone-vacuum cementing tech-
tive bearing surfaces in total hip arthroplasty. J Bone Joint Surg Am. 2006. 88-A nique for the prevention of fat embolism during total hip arthroplasty: A
(4): 706-714. prospective, randomized clinical trial. J Bone Joint Surg Am. 1999. 81(6): 831-
6. Feighan JE, Goldberg VM, Davy D, Parr JA, Stevenson S. The influence of surface- 843.
blasting on the incorporation of titanium-alloy implants in a rabbit 12. Taylor JW, Rorabeck CH. Hip revision arthroplasty: Approach to the femoral side.
intramedullary model. J Bone Joint Surg Am. 77-A; 9:1380-1395. Clin Orthop Rel Res. 1999. 369: 208-222.
7. Barrack RL, Castro F, Guinn s. Cost of implanting a cemented versus cementless 13. Goldberg SH, Cohen MS, Young M, Bradnock B. Thermal tissue damage caused
femoral stem. J Arthroplasty. 1996; 11(4): 373-6. by cement removal from the humerus. J Bone Joint Surg Am. 2005. 87(3): 583-
8. Keisu KS, Orozco F, Sharkey PF, Hozack WJ, Rothman RH. Primary cementless 591.

SYMPOSIA AR HIP
total hip arthroplasty in octogenarians: two to eleven year follow-up. J Bone Joint 14. Nogler M, Lass-Florl C, Wimmer C, Mayr E, Bach C, Ogon M. Contamination
Surg Am. 2001. 83-A(3):359-363. during removal of cement in revision hip arthroplasty. A cadaver study using
9. Lachiewicz PF, Soileau E, Ellis J. Modular revision for recurrent dislocation of pri- ultrasound and high-speed cutters. J Bone Joint Surg Br. 2003. 85(3): 436-439.
mary or revision total hip arthroplasty. J Arthroplasty. 2004. 19(4): 424-429. 15. Morrey BF, Kavanagh BF. Complications with revision of the femoral component
10. Ries MD, Lynch F, Rauscher LA, Richman J, Mick C, Gomez M. Pulmonary func- of total hip arthroplasty: comparison between cemented and uncemented tech-
tion during and after total hip replacement. Findings in patients who have inser- niques. J Arthoplasty. 1992. 7:71-79.
tion of a femoral component with and without cement. J Bone Joint Surg Am.
1993; 75-A:581-7.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
15
SYM 07:Layout 1 1/12/07 11:39 AM Page 16

FEMORAL FIXATION IN OLDER PATIENTS: CEMENTED

Paul F. Lachiewicz, MD

Why consider cement in older patients? Williams et al JBJS(B) 2002

• Immediate fixation • First 325 hips, 8-12 year f/u
• Thigh pain usually avoided • Mean patient age 67.6 years
• No need for “perfect” broaching • 100% femoral survival!
SYMPOSIA AR HIP

• Fixation in large canal

Cemented Femur Results
• More rapid rehab?
Personal series – “rough” stems
• Can use antibiotic in cement
• Precoat® Lachiewicz & Messick J Arthroplasty 2003
Indications 75 hips; mean 10 year f/u
• Patient Mean patient age 67 years
Older, sedentary, > 75 years No femoral loosening
Rheumatoid > 60-65 years • Second generation precoated stem Centralign®
Femoral neck fracture, conversion Sylvain et al J Arthroplasty 2001
• Bone type 12% femoral loosening at 3 years
Severe osteopenia Multiple confounding variables –
Dorr type C Hylamer® liners, young patients, etc.
• Patient had an excellent result from a contralateral cement- Jarret and Lachiewicz J Arthroplasty 2005
ed stem 166 hips: mean patient age 69 years
Mean f/u 7.2 years (5-12)
Don’t Use Cement
Cement grade A or B 95%
• Young patients < 65 years
Results: Well-fixed 97%
• High demand patients
Definitely loose 2.4%
• Obese patients – difficult exposure and cementing tech-
Ten year survival 95%
nique
• Precoat vs Polished Stem
• Older men with specific anatomy: narrow, thick medullary
Prospective, randomized study
canal and large metaphysis
Stems: Ra = 7-12 vs Ra = 70-90
Don’t Use Cement – 67 hips in each group
• Dialysis patient – Mean patient age 73 years
• Bleeding dyscrasia – Mean follow-up 4 years
• Bone marrow disorder – One revision each group
• Severe cardiac or pulmonary disease ? – No difference in surface finish
– Underpowered study if difference in failure rate is
Cemented Femoral Component
only 2%
• Material – CoCr alloy
• Proper design – offset, geometry Personal THA Fixation
• Third generation cementing to get an A or B mantle • 1991 – mid 1997
• Surface finish controversial Cemented 74%
Uncemented 26%
Modern Cement Techniques
• 2001 – 2005
• Rasp only; no power reaming
Cemented 53%
• Plug canal; polyethylene easier than cement plug
Uncemented 47%
• Lavage and pack canal
(2005 68% uncemented)
• Vacuum mixed cement (Simplex P® used by author)
• Cemented THA Patients
• Distal centralizer only
69% women
• Cement gun; pressurize with rubber dam
Mean age 75.8 years
Concerns with Modern Cementing No loosening
• More difficult with “mini” incision One removed – periprosthetic fracture
• Increased OR time
Conclusions
• “Art” of cementing
• Cemented femur is still a reasonable option in 2007 in
Surface Finish Femoral Component selected patients
• Polished • Use “modern” cement techniques
• Matte • Antibiotic cement in “high-risk” patients
• Precoat • Use “high-quality” component
• Macrotextured • Surface finish controversial – probably better to use pol-
ished or matte stem
Cemented Femur Results
• Exeter polished stainless steel stem

REFERENCES 2. Jarrett SD, Lachiewicz PF. Precoated femoral component with proximal and dis-
1. Barrack RL, Mulroy RD, Harris WH. Improved cementing techniques and tal centralizers: results at 5 to 12 years. J Arthroplasty. 2005:20(3):309-315.
femoral component loosening in young patients with hip arthroplasties: A 12-
year radiographic review. J Bone Joint Surg Br. 1992:74-B:385-389.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
16 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 17

3. Lachiewicz, PF, Messick P. Precoated femoral component in primary hybrid total 5. Williams HD, Browne G, Gie GA, Ling RS, Timperley AJ, Wendover NA. The
hip arthroplasty: Results at a mean 10-year follow-up. J Arthroplasty. Exeter universal cemented femoral component at 8 to 12 years. A study of the
2003:18(1):1-5. first 325 hips. J Bone Joint Surg Br. 2002:84(3):324-334.
4. Sylvain GM, Kassab S, Coutts R, Santore R. Early failure of a roughened surface,
precoated femoral component in total hip arthroplasty. J Arthroplasty.
2001:16(2):141-148.

SYMPOSIA AR HIP

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
17
SYM 07:Layout 1 1/12/07 11:39 AM Page 18

A COMPREHENSIVE MULTI-MODAL PAIN MANAGEMENT

PROGRAM FOR TOTAL KNEE AND TOTAL HIP ARTHROPLASTY
Mark W. Pagnano, MD

I. Effective pain management 3. Tylenol 1000 mg 6am; Noon; 6pm on schedule

A. Improves patient satisfaction 4. Oxycodone for breakthrough pain – use a pure nar-
SYMPOSIA AR HIP

B. Decreases hospital stay cotic medication like oxycodone alone (instead of

C. Facilitates discharge to home instead of to assisted care Tylenol #3 for instance) for this as it does not contain
acetaminophen and you can thus avoid overdosing
II. Patient controlled (narcotic) anesthesia – falling from
acetaminophen.
favor
A. Represented a step in the right direction V. Results are dramatic – both in primary and revision set-
B. Smoothed out some of the extreme variations in pain ting
C. Plagued though by substantial side effects A. Patients have little to no pain – typical VAS Pain scores 0-
D. Nausea and vomiting – unable to advance diet 2 on day of surgery and POD 1
E. Oversedation — unable to participate in physical therapy B. Morning of POD#1 patients are alert, oriented, happy,
F. Undermedication – unwilling to participate in therapy; typically ready to order breakfast or are reading the news-
lack of sleep paper on AM rounds
G. Adynamic Ileus – NG tubes, prolonged hospital stay C. Our patients who had PCA pumps for a prior surgery
H. Itching/idiosyncratic reactions to morphine/demerol/fen- and the Multi-modal Approach with Peripheral Nerve
tanyl Block for a subsequent surgery clearly express a decided
preference for the multi-modal approach
III. Substantial recent body of knowledge regarding periop-
D. Catheters can be left in for 48 hours
pain management
E. Surgeons are free to use DVT prophylaxis regimen of
A. Emphasis on multi-modal and pre-emptive approach
their choosing; no contraindication to LMWH or
B. Stay ahead of pain and you limit total analgesia require-
Coumadin with catheter in place
ments
F. Anesthesiologist can adjust the concentration of local
C. Take advantage of benefits of various medications while
anesthetic to selectively target sensory block alone or
staying below threshold for side effects
motor block as well – typically higher concentration and
D. Avoid the use of parenteral narcotics
combined sensorimotor block on day of surgery and first
IV. Components of Multi-modal strategy evening then taper to sensory only on POD #1 then pull
A. Preoperative administration of medication catheter at 36-48 hours.
1. Long-acting oral narcotic (Oxycontin) G. We know of one group of surgeons who now use this
2. Oral anti-inflammatory: typically a Cox-II (Celebrex) protocol in conjunction with traditional open surgery
3. Begin night before or morning of surgery and tout to patients that they offer “the pain-free
B. Regional anesthesia approach to THA and TKA”
1. Peripheral nerve blocks – most selective
VI. Barriers to introduction
a. Psoas compartment block – indwelling catheter;
A. Training anesthesia staff on technique of peripheral
figure on left below shows distribution of psoas
nerve blockade
block.
1. Technique well within the grasp of most anesthesiolo-
b. Sciatic nerve block – single shot vs. indwelling; fig-
gists
ure on right below shows distribution of sciatic
2. Added reimbursement for these blocks now provides
block.
an incentive for them to learn
c. If these peripheral nerve blocks are placed pre-
3. Most effective if done in a separate block room prior
operatively by a different anesthesiologist than the
to surgery – this improves efficiency both for surgeon
one who does your intra-op anesthesia they can be
and anesthesiologist
billed for separately; you now have a major incen-
B. Nursing resistance
tive for your anesthesia colleagues to get organized
1. Many are reluctant to give up PCA pump convenience
and have blocks in place for your next case; limit
2. Delivering medications on schedule more taxing
turnover time; improve your productivity at same
3. Disbelief that THA/TKA and revisions can be done
time you improve patient care
without requiring large doses of parenteral narcotics
• Iliac crest (IC)
4. Get your nurses through the initial phase and they’ll
• Midline lumbar spine
be happy to deliver regular doses of Tylenol and Vioxx
• Posterior superior iliac spine (PSI)
when they find out that majority of patients are no
• Iliac crest (IC)
longer vacillating between marked pain and excessive
• Midline lumbar spine
somnolence or ongoing nausea and vomiting
• Posterior superior iliac spine (PSI)
2. Spinal anesthesia VII. Downsides
3. Epidural anesthesia A. Initial learning curve with anesthesia can be frustrating –
C. Postoperative Analgesia sometimes they miss or get incomplete blocks
1. Oxycontin 10-20 mg bid on schedule B. Takes some time to do blocks – if problems encountered
2. Celebrex 200-400 mg qday x 3 days or Toradol 15mg can slow your day down as compared to general anesthe-
IV q6 hr prn 3 doses POD #1 then Celebrex sia
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
18 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 19

C. Sensorimotor blockade limits muscle function so weight- C. Introduction of MIS surgery allows you and me an effec-
bearing on that extremity the day of surgery or POD#1 tive way to institute a program like this
more difficult. 1. Use MIS as your rallying point
D. As experience is gained these deficiencies can be over- 2. Organize your anesthesia colleagues to help you
come and ultimately the skilled anesthesiologist can 3. Garner institutional support for this initiative through
facilitate outpatient surgery using this approach. ability to decrease length of stay and improve satisfac-
tion
VII. Major benefits
4. Involve nursing and physical therapy in entire process
A. Clear benefits for our patients
5. Improve your overall efficiency in OR
B. Applicable to all types of major lower extremity surgery:

SYMPOSIA AR HIP
primary THA (MIS, mini and traditional); primary TKA
(MIS, mini, traditional) and Revision THA and TKA

REFERENCES 4. Perioperative Administration of Rofecoxib for Total Knee Arthroplasty. J

1. Scott S. Reuben,MD; Neil Roy Connelly,MD and Holly Maciolek,RN: Arthroplasty 2002; 17:26-31
Postoperative Analgesia with Controlled-Release Oxycodone Anesth Analg 1999; 5. Singelyn, Anesth Analg 1998 Continuous Femoral Nerve Block in TKA.
88:1286-91 6. Ben-David, Anesth Analg 2003 Sciatic Nerve Block in TKA.
2. Scott S. Reuben,MD; Richard Fingeroth,MD; Robert Krushell,MD and 7. Weber, Eur J Anaesthesiol 2002 Sciatic Nerve Block in TKA.
3. Holly Maciolek,RN: Evaluation of the Safety and Efficacy of the 8. Stevens, Anesthesiology 2000 Psoas Compartment Blockade in THA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
19
SYM 07:Layout 1 1/12/07 11:39 AM Page 20

PERIOPERATIVE PAIN MANAGEMENT: PRE-OPERATIVE ORAL

ANALGESICS: MINIMIZING INTRAVENOUS NARCOTICS
Jay R. Lieberman, M.D.

I. Introduction III. Pathophysiology

A. Evolution of Total Hip Arthroplasty A. Tissue Injury and Pain Response
SYMPOSIA AR HIP

1. Over the past 5 years significant changes have 1. Surgery causes injury to tissue which initiates a sys-
occurred with respect to total hip arthroplasty includ- temic reaction that includes an increase in proinflam-
ing the use of minimal incision surgery and more matory cytokines.
aggressive rehabilitation regimens. However the most a. This cytokine release induces both central and
significant change related to total hip arthroplasty has peripheral system sensitization which is associated
been the advent of new pain protocols that not only with hyperalgesia and COX-2 activity. Furthermore,
provide excellent pain relief which facilitates rehabili- surgical trauma reduces the threshold for afferent
tation but also limit the post-operative side effects nocioceptive neurons which leads to postoperative
associated with more traditional pain regimens. pain hypersensitivity. There is not only a decrease
in the pain threshold but the response to noxious
II. Standard Analgesic Regimens
stimuli is magnified..
A. Epidural Analgesia
2. PGE2 is the predominant eicosanoid released after
1. Provides some pain relief
surgical trauma and has been associated with inflam-
2. Associated with numerous side effects including:
mation, pain and fever.
a. Spinal headache
3. Surgery leads to a complex systemic response that
b. Neurogenic bladder
leads to elevations in both plasma PGE2 and inter-
c. Hypotension
leukin 6. (Buvanendran et al, Anesthesiology, 2006).
d. Respiratory depression
a. Total hip arthroplasty leads to both central and
e. Cardiac decompensation
local elevations of PGE2, IL-6 and IL-8
B. Opiod drugs and Patent-Controlled Analgesia
b. Hip surgical site fluid elevation of PGE2, IL-6 and
1. May deliver opiod intravenously via patent-controlled
IL-8 were higher than in the plasma
analgesia
i.) The elevations in the hip surgical site fluid did
2. PCA produces satisfactory pain relief
not come from CSF.
a. Advantages of PCA: fairly easy to administer and
4. COX-2 inhibitors can be used to limit both CSF and
can be titrated
surgical site PGE2 level and CSF IL-6 levels.
b. Disadvantage: may not provide adequate pain relief
B. Preemptive Analgesia
with movement after total joint arthroplasty
1. Initiate analgesia prior to the onset of noxious stimuli
3. Side Effects
that can lead to cytokine release and sensitization of
a. Nausea and vomiting
the nervous system.
b. Respiratory depression
2. The goal is to block the transmission of noxious affer-
c. Drowsiness
ent stimuli from the peripheral nervous system to the
d. Pruritus
spinal cord and brain.
e. Ileus
a. It is essential that analgesic agents be administered
f. Urinary retention
prior to the incision and to be of sufficient strength
Therefore, local analgesia at the site of surgical trauma com- to limit the sensitization of the nervous system.
bined with preemptive analgesia is an attractive option. The b. COX-2 inhibition therapy can be used to block the
goal is to avoid intravenous narcotics. inflammatory and prostanoid-mediated responses
associated with total joint replacement.
IV. Pain Management Regimens
A. Multimodal Analgesia
1. The goal of multimodal analgesia is to maximize pain
relief while limiting side effects.
a. The side effects associated with pain regimens are
often secondary to the use of opiods.
b. The goal is to use both regional anesthesia, and
pre-operative and postoperative analgesia in order
to limit opiate use.
c. Patients may receive COX-2 inhibitors pre-opera-
tively to the limit prostaglandin release generally
associated with surgery. This PG release sensitizes
the central nervous system. COX-2 inhibitors can
be combined with analgesic medication (oxyco-
dine) just prior to the procedure to limit sensitiza-
tion of the nervous system. However, the agents
have limited effect at the surgical site.
2. Use of surgical site infiltration coctails
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
20 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 21

a. Use of infiltration mixtures is well-documented in Summary

total knee arthroplasty (Busch et al, JBJS, 2006) A multimodal pain protocol can enhance the outcome of THA
and has been recently reported for total hip arthro- patients during the hospital stay.
plasty (Maheshwari, et al, Clin Orthop, 2006).
i.) Richard Berger M.D. and Lawrence Dorr, MD
should be given credit for developing these pain
protocols that avoid the use of parenteral nar-
cotics (See Appendix for protocols)
3. A variety of different agents are used in infiltration

SYMPOSIA AR HIP
mixtures. The most standard agents are listed below.
a. Epimorphine – Peripheral inflamed tissues contain
opiod receptors that are expressed within hours of
surgical trauma. These receptors may be responsi-
ble for providing afferent sensing input to the CNS.
b. Ropivacaine – The main action of this agent is to
block afferent peripheral nocioceptive activity. This
drug has less cardiac and CNS toxicity than bipuvi-
caine. Approximately 30 minutes after injection the
maximum circulating level of the drug is attained.
c. NSAIDs – Inhibition of the eisaconoid pathway
prevents production of inflammatory mediators
which limits peripheral sensitization and activation
of nocioreceptors.
d. Epinephrine – Keeps local anesthetic agents from
diffusing out of surgical site and thus limits toxicity.
e. Other agents that have been used.
i.) Methylprednisolone acetate to limit inflamma-
tion but there are concerns about effects of Above: Landmarks for the Psoas compartment block include
steroids on wound healing and infection. the Iliac Crest (1) the Posterior Superior Iliac Spine (2)
ii.) Antibiotics – Use antibiotics to kill local bacte- and the midline of the lumbar spine palpating the
ria but their efficacy locally is unknown. spinous processes then sliding over to the transverse
processes.
V. Treatment Regimen Results
A. Multimodol analgesia for THA (Maheshwari, et al, Clin Below: Landmarks for the Sciatic nerve block include the
Orthop, 2006) Posterior Superior Iliac Spine, the Greater Trochanter
1. Retrospective review of 138 pts. who underwent pri- and the base of the sacrum.
mary THA and received a specific multimodal anal-
gesic protocol which included: preoperative celecoxib,
acetaminophen and oxycodone; a epidural anesthetic
and local infiltration of a cocktail that contained
ropivicaine, morphine and methyl predinisolone at
the end of the procedure and ketorolac, oxycodone
and a COX-2 inhibitor post-operatively.
2. The protocol provided effective pain relief with mini-
mal side effects.
a. Post-operative parenteral narcotics – 15%
b. Parenteral narcotics after the day of surgery – 6.4%
c. Urinary retention – 2.4%
d. Nausea – 25% in RR and 20% during hospital stay
e. Ileus – 0%
f. Pain relief - 3 of 10 on a visual analogue scale on
all days

REFERENCES: 4. Buvanendran A, Kroin JS, Berger RA, Hallab NJ, Saha C, Negrescu C, Moric M,
1. Beyers RA, Jacobs JJ, Meneghini RM, et al. Rapid rehabilitation and recovery with Caicedo MS, Tuman KJ. Upregulation of prostaglandin E2 and interleukins in
minimally invasive total hip arthroplasty. Clin Orthop 2004; 429:233-49. the central nervous system and peripheral tissue during and after surgery in
humans. Anesthesiology 2006; 104:403-10.
2. Bush CA, Shore BJ, Bhandasi R, Et al. Efficacy of periarticular multimodal drug
injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am 5. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesia for total hip and knee
2006; 88:959-63. arthroplasty: a multimodal pathway featuring peripheral nerve block. J Am Acad
Orthop Surgy 2006; 14:126-35.
3. Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M,
Rosenberg AG. Effects of perioperative administration of a selective cyclooxyge- 6. Maheshwari AV, Boutary M, Yun AG, Sirianni LE, Dorr LD. Multimodal analge-
nase 2 inhibitor on pain management and recovery of function after knee sia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop
replacement: a randomized controlled trial. JAMA 2003; 290:1411-18. 2006; in press.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
21
SYM 07:Layout 1 1/12/07 11:39 AM Page 22

Appendix 4. Epinephrine (1:1000) 0.6mg

I. Modification of protocol of Busch et al used originally for These agents are mixed with sterile saline to reach a vol-
total hip replacement patients. Each surgeon needs to select ume of 100 mg. You can half the doses if 50 ml is going
a protocol that can be used effectively in their institution. to be used.
The protocol should be reviewed with your anesthesia staff
Recovery Room
prior to implementation.
1. Pull epidural catheter in RR
Pre-operative protocol: 2. Keterolac 30 mg N – one dose in RR and one dose 6
1. Begin Celebrex 200mg 3 days prior to surgery (clear hours later
with the internist) 3. Percocet 1-2 tabs PO 4h prn pain
SYMPOSIA AR HIP

2. Celebrex 200 mg PO pior to surgery (no NSAID if 4. Anzemet for nausea 12.5 mg V in RR and then q 6 hr
patient has sulpha allergy)
Floor Program
3. Oxycontin 10 mg PO prior to surgery
Percocet 1-2 tabs PO q 4 hour prn and switch to
Intraoperative – infiltration mixtures Vicocden on post-operative day #2 Vicodin 5 mg/500
(Discuss with anesthesiologist to see if there is any prob- mg 1-2 tab PO Q3-4h prn pain and for discharge
lem giving local injection of ketorolac and epineph- Morphine 2-4 IM for breakthrough pain on the night
rine). The total volume is 150 ml. of surgery.
1. Ropivacaine 400 mg (Note: See Maheshwari, Clin Orthop, 2006 for alterna-
2. Ketorolac 30 mg tive protocol. Protocol by L Dorr)
3. Epimrphine 5 mg

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
22 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 23

EARLY PERIOPERATIVE COMPLICATIONS OF

THR: CONTEMPORARY PREVENTION AND

SYMPOSIA AR HIP
TREATMENT (N)
Moderator: Arlen D. Hanssen, MD Rochester, MN (c, e - Stryker)

Expert based symposium detailing the contemporary methods of prevention and treatment
of the most common perioperative complications associated with total hip arthroplasty.

I. Dislocation
William J. Maloney, MD, Stanford, CA
(a - DePuy, Medtonics, c - Zimmer, Wright Medical)

II. Limb-Length Inequality

Lawrence D. Dorr, MD, Inglewood, CA (a, c - Zimmer)

III. Intraoperative Fractures

Miguel E. Cabanela, MD, Rochester, MN (a, c, e - Stryker)

IV. Infection
Arlen D. Hanssen, MD Rochester, MN (c, e - Stryker)

V. Neurovascular Injuries
Thomas P. Schmalzried, MD Los Angeles, CA (a,c,e - DePuy Orthopaedics,
Stryker Orthopaedics, a - Wright Medical Technology, Corin USA)

VI. Heterotopic Ossification

Vincent D. Pelligrini, MD Baltimore, MD
(a - Kabi-pharmacia, Sanofi-Synthelabo, Kendall)

VII. Deep Venous Thrombosis

a. Aspirin/Multimodal
Eduardo A. Salvati, MD, New York, NY (n)
b. Warfarin
Jay Lieberman, MD, Farmington, CT (a,e - DePuy)
c. LMWH and newer agents
Clifford Colwell, MDLa Jolla, CA (a - AstraZeneca, Bayer Healthcare, Sanofi-Aventis,
Boehringer)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
23
SYM 07:Layout 1 1/12/07 11:39 AM Page 24

DISLOCATION
William J. Maloney, MD

Dislocation following total hip replacement is still one of the a 28 to a 32 to a 36 mm. or larger femoral head, one can almost
most common and important early perioperative complications. eliminate implant on implant impingement.
Review of the Medicare data suggest that it occurs in approxi-
Evaluation of the unstable hip requires a history, a physical exam
mately 3% of primary total hip replacements and upwards of 9-
and review of the radiographs. From a historical standpoint, the
SYMPOSIA AR HIP

10% in revision total hip replacements.

surgeon would want to know the timing of dislocation. Was the
Prevention of dislocation following total hip replacement begins dislocation an anterior dislocation or posterior dislocation? What
with the index procedure. Preoperative planning helps the sur- specific activities was the patient doing during the time of dislo-
geon develop an approach in which he/she can restore hip bio- cation? How many times has the patient dislocated? Finally, what
mechanics through restoration of the hip center, femoral offset surgical approach was utilized and are there any signs of chronic
and leg length. In so doing, one not only optimizes the hip joint low grade infection which can be associated with hip instability?
reaction forces but restores abductor tension in such a way to aid
On physical examination, the surgeon should note the skin inci-
in hip stability.
sion which in part will confirm the surgical approach. Muscle
Intraoperatively, the acetabular implant position is an important strength, especially that of the abductors, should be assessed.
factor as it relates to hip stability. Following insertion of trial com- There are a small number of cases in which a direct lateral
ponents, a trail reduction should be done to assure that the hip is approach was used and the abductors have avulsed. Those
stable through a functional range of motion. Careful assessment patients will walk with a trendelenburg gait, have weak abductor
for impingement is critical. The most common forms of impinge- strength and will be unstable as a result. Sometimes a defect can
ment are bone on bone and implant on implant. Bone on bone be palpated in the lateral aspect of the hip in those cases. Leg
impingement is most common in flexion and internal rotation length should also be assessed.
where the anterior aspect of the remaining femoral neck or greater
Radiographs are important in evaluating a patient with a chron-
trochanter impinges on the pelvis. Restoration or a slight increase
ic unstable hip in which one is considering re-operation. It is
in femoral offset will minimize bone on bone impingement. In
helpful to have a good AP pelvis x-ray both pre- and post surgery
addition, the surgeon can resect any bony osteophytes off the
for comparison. In addition, a cross table lateral is a valuable x-
acetabulum and/or anterior aspect of the trochanter or femoral
ray to look at acetabular component positioning. The following
neck to reduce the chance of bone on bone impingement.
variables should be assessed:
Retrieval studies have demonstrated that implant on implant
1. Acetabular abduction
impingement is common. This type of impingement is probably
2. Acetabular anteversion
responsible for a large percentage of hip dislocations. It can occur
3. Femoral offset compared to a preoperative offset
in flexion and internal rotation where the femoral neck impinges
4. Leg length compared to preoperative leg length
on the anterior aspect of the acetabular component. It also can
occur in extension and external rotation where the femoral neck This analysis will allow the surgeon to determine the cause of
impinges on the posterior aspect of the acetabular component. It dislocation in the majority of cases. Once the cause has been
may be more common with the use of elevated rim liners. identified, then a surgical plan can be formed.
However one study has also shown that elevated rim liners reduce
Typically, a malpositioned acetabular component should be
the early rate of postoperative dislocation. Impingement is also a
revised. Smaller degrees of component malposition can often be
problem when there is a significant discrepancy between a
dealt with a combination of liner options and larger femoral
femoral head size and acetabular component size. Paprosky
heads. Larger femoral heads again will help reduce implant on
demonstrated that with 28 mm. heads, impingement was more
implant impingement and elevated rim liners will increase hip
common when the socket size was 58 mm. or greater. This is in
stability in the direction of instability. One has to be careful that
part a justification for use of larger femoral heads. Larger femoral
one doesn’t create an unstable situation in the opposite direction
heads will be discussed in more detail below.
with an elevated line. Offset liners will help push the femur away
The posterior surgical approach has been historically associated from the pelvis and improve bone on bone impingement.
with an increased rate of hip dislocation. However, with posteri- Resection of osteophytes or excessive scar tissue anteriorly may
or capsular repair as well as repair of the short external rotators, also help with impingement in flexion and internal rotation.
several studies have demonstrated a marked reduction in dislo- Constrained liners are primarily, at least in my opinion, used in a
cation. Currently, surgical approach is not considered a key fac- salvage situation and are somewhat of a last resort. They are best
tor as it relates to postoperative dislocation. used for low demand patients who have relatively well positioned
implants but have a poor abductor mechanism with either chron-
With the availability of large femoral heads with both metal on
ically compromised abductor musculature or an avulsed tendon.
metal and metal on polyethylene articulations, there has been a
They also can be very helpful in low demand elderly patients who
marked increase in their use. Although there are theoretical long-
simply can’t remember the precautions for dislocation or are at
term considerations, the impact on hip stability is in my opinion
chronic risk for dislocation even with well positioned implants.
the major driving force behind their market acceptance. It’s clear
from the laboratory studies that increasing the femoral head size It’s important to remember when speaking to the patient about
as it relates to femoral neck diameter increases your impinge- re-operation that the success rate based on published reports is
ment free range of motion. This addresses only implant on in the neighborhood of 70%. That success is dependent on care-
implant impingement and does not have an impact on other ful preoperative evaluation, identification of the mechanism of
types of impingement. However as one goes from a 22 to a 26 to dislocation and the addressing of that mechanism at the time of
revision surgery.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
24 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 25

LIMB LENGTH INEQUALITY

Lawrence D. Dorr, MD

Prevention and treatment of limb length inequality is of critical The final check of leg lengths is again done by the choice used
importance to the patient. It may be the most important social by the surgeon of either pins, comparing the operative leg to the
goal of the patient to walk without a limp and not use a shoe contralateral leg in either the supine or the lateral position,
lift. Prevention of limb length requires preoperative planning and/or by anatomical measures. Anatomic measures of the off-

SYMPOSIA AR HIP
and understanding of how much difference in the limb length set involve clearance of bony contact throughout the range of
is present and whether or not that leg length can be corrected. motion by one fingerbreadth and the best anatomical measure
Education of the patient on the ability to correct leg length and for leg length is the position of the lesser trochanter to the ischi-
the chance that leg length will not be equal is very important. It um. The final, final check for leg length is done with the patient
is critical that the patient have the correct expectations on leg supine on the table at the completion of the operation. The two
length. legs should be lifted to be sure there is no influence of any flex-
ion contracture in either hip. An x-ray can be taken in the oper-
Intraoperatively, there are several choices for techniques used to
ating room to confirm the position of the operated hip to the
manually measure leg length. These include the use of pins,
unoperated hip (if it is not abnormal).
comparison of one leg to the other, and anatomical landmarks
within the hip. The operative techniques critical for creating Correction of leg length inequality should be done immediate-
equality of leg lengths include the cup position. Lateralization ly if it is found in the operating room. If leg length inequality
of the cup is one of the most common reasons for a long leg. If has been created to prevent impingement, then the source of the
the cup is lateralized the leg often needs to be lengthened to pre- impingement should be ascertained and eliminated so that the
vent impingement and intraoperative instability. The position offset and leg length can be corrected to near normal. If the leg
of the cup is best determined by the edge of the metal shell at length was lengthened because of instability caused by reasons
the level of the cortical bone of the cotyloid notch and at the other than impingement it almost always is because of the cup
anterior-superior bony edge of the acetabulum. If the cup does position and this must be evaluated. If we find this during the
not overhang at these two sites it is not lateralized. Computer operation it is easiest to correct, however, we will again open the
navigation is a great help in positioning the cup because it not wound and correct the cause of leg length inequality if we find
only allows accurate inclination and anteversion, but also the it present on the final, final check and/or the postoperative x-
quantitative change in the center of rotation of the hip is ray. Correction of leg length after the day of operation has a
known. The computer navigation simply acts as high technolo- much greater psychological impact on the patient and the fam-
gy instrumentation though, and the surgeon must still deter- ily of the patient. It usually requires much more extensive sur-
mine whether correct coverage is present. On the femoral side gery than if done when discovered on the day of surgery.
the level of the neck cut is critical information because the level Correction in the first three months is the second easiest time
at which time the femoral stem is seated will have a major for reoperation because the components are not solidly fixed (if
impact on the leg length and offset. Finally, intraoperatively the cementless fixation was used). If the cup had previously been
surgeon must determine that bone impingement is not present. lateralized the problem should be corrected by changing the
If it is present either the leg length or the offset is not correct. The cup. If the leg length was created because of instability caused by
most important measure for the combination of leg length and incorrect femoral version then the femoral component will have
offset is the relationship of the lesser trochanter to the tip of the to be changed. Correction after three months, or when compo-
ischium. This must clear the ischium in full extension and with nents are solidly fixed becomes true revision surgery and what-
rotation by 1 fingerbreadth and must be above the tip of the ever revision operation is necessary is done. One choice is to
ischium by a full fingerbreadth. correct the length with a supracondylar osteotomy at the knee
rather than changing the femoral components if the femoral
components are well fixed and well positioned.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
25
SYM 07:Layout 1 1/12/07 11:39 AM Page 26

INTRAOPERATIVE FRACTURES DURING PRIMARY

TOTAL HIP ARTHROPLASTY
M. E. Cabanela, MD

ACETABULUM Intraoperative fractures occur more frequently in revision than

Intraoperative acetabular fractures are rare and often unrecog- in primary surgery. They can be classified into three types:
SYMPOSIA AR HIP

nized or recognized only postoperatively. Predisposing factors

include: 1) acetabular deficiency (protrusio, dysplasia, dwarfing Proximal fractures
conditions); 2) impaired bone quality (osteoporosis, osteoma- A) Greater trochanteric fractures: these occur, typically in the
lacia, OI, Paget’s disease, osteoradionecrosis); 3) surgical tech- process of rasping, (particularly when withdrawing the rasp)
nique (under or overreaming, cup sizing, cup design). or in the process of driving a tight metaphyseal filling pros-
thesis. These fractures should be fixed securely although if
Prevention of intraoperative fractures includes proper surgical
the abductor mechanism is well in continuity, sometimes
technique. This encompasses altering the technique to adjust
they can be ignored.
reaming to the bone quality (line to line reaming in osteoporot-
B) Medial anterior or posterior cracks related to increased
ic bone to avoid insertional fractures). If fracture occurs at cup hoop stresses at the time of prosthetic implantation. These
insertion, the goals of treatment include the achievement of sta- should not be ignored. The standard treatment would be
ble fracture and also stable fixation of the socket. This requires partial removal of the prosthesis, insertion of a circumferen-
ancillary fixation of the socket with the screws and if necessary, tial wire or cable, tightening of the wire or cable and rein-
internal fixation of the fracture with plate and screws. One should sertion of the prosthesis. If this technique is followed the
also add bone graft, preferably autograft, to the fracture and alter ultimate results of the arthroplasty are not altered.
the postoperative rehabilitation and weightbearing as indicated.
Fractures that start at the tip of the prosthesis
FEMUR. These are related more commonly to diaphyseal filling unce-
The etiology of intraoperative femoral fractures has varied mented prostheses.
through the years. In the 1970’s during the era of cemented
femoral components, intraoperative fractures occurred either as A) Fractures starting at the tip of the prosthesis.
1) These can be oblique fractures that exit through the cor-
the result of difficult exposure ( femoral perforation during
tex. If recognized intraoperatively, this should be treated
preparationor insertion of the femoral component) or surgical
by circumferential cable and/or strut graft. Seldom, a
dislocation of the hip (in this instance, they were often spiral
longer prosthesis may be necessary.
fractures). As the knowledge of thess complications increased
2) Sometimes, they are longitudinal tracks distal to the tip
and our ability in dealing with femoral revision improved, the
of the prosthesis that do not seem to exit but are clearly
incidence of this problems decreased.
visible in at least one of the postoperative x-rays. This in
In the 1980’s during the introduction of cementless femoral general can be ignored and partial weightbearing is all
components, the nature of intraoperative femoral fractures that is necessary. The fracture line typically disappears in
changed. They occurred during preparation of the femur with 8 to 14 weeks..
metaphyseal filling rasps or during insertion of a metaphyseal
Distal fractures.
filling stem.
These are usually the result of rotational maneuvers during arthro-
Again, understanding of the nature of these fractures, prophylax- plasty and have to be treated as any other fracture at that level.
is by use of circlage fixation and the use of implants associated
While prevention is preferable, if these fractures occur they
with less incidence of this complication reduced that incidence.
should be treated vigorously. Under-treatment is associated
Lately, the advent of minimally invasive arthroplasties, especial- with further displacement and unsatisfactory results. It is better
ly the two-incision procedure, has led to an increase of intraop- to spend additional time to obtain stable fixation and a stable
erative fractures. prosthesis as the situation will not improve once the patient
leaves the operating room.

REFERENCES tures associated with cementless acetabular component insertion. J Arthroplasty.

1. Archibeck MJ, White RE Jr. Learning curve for the two-incision total hip replace- 2004 Aug;19(5):643-6.
ment. Clin Orthop Relat Res. 2004 Dec;(429):232-8. 8. Kold S, Mouzin O, Bourgeault C, Soballe K, Bechtold JE.Femoral fracture risk in
2. Berend KR, Lombardi AV Jr, Mallory TH, Chonko DJ, Dodds KL, Adams JB. hip arthroplasty: smooth versus toothed instruments. Clin Orthop Relat Res.
Cerclage wires or cables for the management of intraoperative fracture associated 2003 Mar;(408):180-8
with a cementless, tapered femoral prosthesis: results at 2 to 16 years. J 9. Mont MA, Maar DC, Krackow KA, Hungerford DS. Hoop-stress fractures of the
Arthroplasty. 2004 Oct;19(7 Suppl 2):17-21. proximal femur during hip arthroplasty. Management and results in 19 cases. : J
3. Cameron HU. Intraoperative hip fractures: ruining your day. J Arthroplasty. 2004 Bone Joint Surg Br. 1992 Mar;74(2):257-60
Jun;19(4 Suppl 1):99-103. 10. Moroni A, Faldini C, Piras F, Giannini S. Risk factors for intraoperative femoral
4. Fitzgerald RH Jr, Brindley GW, Kavanagh BF. The uncemented total hip arthroplas- fractures during total hip replacement. Ann Chir Gynaecol. 2000;89(2):113-8.
ty. Intraoperative femoral fractures. Clin Orthop Relat Res. 1988 Oct;(235):61-6. 11. Sharkey PF, Hozack WJ, Booth RE Jr, Rothman RH. Intraoperative femoral frac-
5. Herzwurm PJ, Walsh J, Pettine KA, Ebert FR. Prophylactic cerclage: a method of tures in cementless total hip arthroplasty. Orthop Rev. 1992 Mar;21(3):337-42.
preventing femur fracture in uncemented total hip arthroplasty. Orthopedics. 12. Sharkey PF, Hozack WJ, Callaghan JJ, Kim YS, Berry DJ, Hanssen AD, Lewallen
1992 Feb;15(2):143-6. DG. Acetabular fracture associated with cementless acetabular component inser-
6. Incavo SJ, DiFazio F, Wilder D, Howe JG, Pope M. Longitudinal crack propagation tion: a report of 13 cases. J Arthroplasty. 1999 Jun;14(4):426-31.
in bone around femoral prosthesis. Clin Orthop Relat Res. 1991 Nov;(272):175-80. 13. Toni A, Ciaroni D, Sudanese A, Femino F, Marraro MD, Bueno Lozano AL,
7. Ko PS, Chan WF, Wong MK, Leung MF, Lee OB, Lam JJ. Fixation using acetabular Giunti A.Incidence of intraoperative femoral fracture. Straight-stemmed versus
reconstruction cage and cancellous allografts for intraoperative acetabular frac- anatomic cementless total hip arthroplasty. Acta Orthop Belg. 1994;60(1):43-54.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
26 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 27

INFECTION
Arlen D. Hanssen, MD

I. Prevention: Requires vigilance in the preop, intraop, and Postoperative Time Period
postop time periods.7 Wound Environment: Choice of anticoagulation (LMWH vs
a. Reduction of bacterial contamination mechanical)16
b. Augmenting the host response • Post-discharge surveillance programs8

SYMPOSIA AR HIP
c. Optimize the wound environment Bacterial Reduction: (Antibiotic prophylaxis / High Risk
Antibiotics: Prophylactic antibiotics are single most effective Procedures)10
prevention method.6 • Invasive procedures: (GI, GU, Dental)
• First generation cephalosporins remain drug of choice due • Urinary tract management,9 remote sites of infection,
to cost, effectiveness, and low toxicity. Alternative antibiotics intravenous catheters
are usually vancomycin or clindamycin. Current standard • Proper and timely management of wound healing prob-
for duration is 24 hours postop. lems
Host Factors: (Patients at Risk)
Indications for antibiotic alternatives include:
• Inflammatory arthropathies: RA, SLE
1) True beta-lactam allergy: < 10% of PCN or cephalosporin
• Disease, drug- or radiation-induced immunosuppression
“allergies” test positive.12
• Insulin-dependent (Type-I) diabetes
2) High prevalence of resistant prosthetic joint infections with-
• First 2 years following joint replacement
in institution (rare).
• Previous prosthetic joint infections
Risk Factors 1 • Malnourishment
Rheumatoid arthritis, steroid therapy, diabetes mellitus, prior • Hemophilia
septic arthritis, prior arthroplasty, malignancy, lymphocytes < • Malignancy
1.5 x 109, >4 hospital days prior to TJR, NNIS >1, homologous
II. Diagnosis: Requires high index of suspicion which is com-
blood transfusion, duration of hospitalization, superficial
plicated by many aspects of natural history of postoperative
wound infection, wound drainage, wound hematoma, wound
recovery following THR.
dehiscence, decubitus ulcers
a. Fever: present in up to 80% of all patients
Preoperative Time Period b. Pain: difficult to assess whether infection, hematoma,
Bacterial Reduction: patient tolerance
• Oral cavity: evaluate and correct preop c. ESR and CRP not helpful in early period of first few
• Pulmonary / GU tract: CXR, urinalysis weeks
• Skin: venous stasis ulcers, infected ingrown toenails, web d. Serum IL-6: promising new approach for early postop
space skin breaks, follicular infection (groin); preopera- infections 4,13
tive showers, shaving e. Imaging studies: not helpful in early postop period
• MRSA preadmission screening 17 f. Wound drainage: often mismanaged with empiric antibi-
Host Augmentation: otics which eliminates window of opportunity for
• Altered immune system14/Diabetes mellitis/Malnutrition: debridement and prosthesis salvage. Careful wound clo-
optimize medically21 sure and early intervention for persistent drainage, in the
• Rheumatoid arthritis / Immunosuppressive medications: absence of antibiotics, are cornerstones of treatment.
stop or reduce dosage
III. Infected THR Classification 20
• Advanced age / High anesthetic risk: consider multi-
Type 1: (PIOC): Positive intraoperative culture 4-6 weeks of
modal anesthesia protocols
antibiotics
Wound Environment:
Type II: (EPOI): Early postoperative infection prosthesis sal-
• Vascular disease, scarring, radiation, psoriatic plaques,
vage possible
thin & atrophic skin
Type III: (LCI): Late chronic infection prosthesis removal
Intra-Operative Time Period required
Bacterial Reduction: Type IV: (AHI):Acute hematogenous infection prosthesis sal-
• Antibiotics: 30 minutes prior to incision; additional vage possible
intravenous dosing, antibiotic irrigation solutions, antibi-
(PIOC): Positive Intraoperative Culture(s):
otic-loaded bone cement (high-risk patients)
Frequently due to lack of adequate preoperative assessment pro-
• OR Protocol: Duration of procedure, instrument steriliza-
tocol for revision THR that includes ESR, CRP, and joint aspira-
tion, operative site preparations, draping, minimize # of
tion, and use of intraoperative histologic evaluation. Newer
personnel, face masks, exhaust gowns, hand scrubs, suck-
technologies that help provide intraoperative guidance as well
ers, splash basins, double gloves, clean-air technologies
as improved postoperative cultures are in development.15,18
(laminar airflow, UV light)
Retrieval of 3 tissue specimens for culture helps guide postoper-
Wound Environment:
ative decision process. One positive culture in broth only is usu-
• Surgical Technique: Adept & proficient exposure, careful
ally a contaminant but is micro-organism specific. Two or more
tissue handling to avoid devitalized & necrotic tissue, and
positive cultures with the same organism is usually treated by 4-
duration of procedure. Frequent irrigation to remove clot
6 weeks of intravenous antibiotics and additional oral antibi-
and avoid tissue dessication. Dead space elimination
otics depending upon specific circumstances.
with subcutaneous sutures and drains. Good wound clo-
sure is vital (epidermal apposition, staples, subcuticular
vs mattress)
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
27
SYM 07:Layout 1 1/12/07 11:39 AM Page 28

(EPOI): Early Postoperative Infection — Success possible in 50-75% of Type II and 50% of
• Antibiotic Suppression: not indicated for early postoper- Type IV infections
ative infections. — Success related to duration of symptoms (eg. S. aureus
• Debridement with Prosthesis Retention: 3,5,11,19 < 48 hours)2
• Treatment of choice for established or highly probable — Do not attempt in Type III (chronic) infections: uni-
infection. versal failure
SYMPOSIA AR HIP

REFERENCES 12. Li, J. T.; Markus, P. J.; Osmon, D. R.; Estes, L.; Gosselin, V. A.; and Hanssen, A. D.:
1. Berbari, E. F.; Hanssen, A. D.; Duffy, M. C.; Steckelberg, J. M.; Ilstrup, D. M.; Reduction of vancomycin use in orthopedic patients with a history of antibiotic
Harmsen, W. S.; and Osmon, D. R.: Risk factors for prosthetic joint infection: allergy. Mayo Clin Proc, 75(9): 902-6, 2000.
case-control study. Clin Infect Dis, 27(5): 1247-54, 1998. 13. Minetto, M. A.; Oprandi, G.; Saba, L.; Mussino, S.; Aprato, A.; Masse, A.; Angeli,
2. Brandt, C. M.; Sistrunk, W. W.; Duffy, M. C.; Hanssen, A. D.; Steckelberg, J. M.; A.; and Gallinaro, P.: Serum interleukin-6 response to elective total hip replace-
Ilstrup, D. M.; and Osmon, D. R.: Staphylococcus aureus prosthetic joint infec- ment surgery. Int Orthop, 30(3): 172-6, 2006.
tion treated with debridement and prosthesis retention. Clin Infect Dis, 24(5): 14. Parvizi, J.; Sullivan, T. A.; Pagnano, M. W.; Trousdale, R. T.; and Bolander, M. E.:
914-9, 1997. Total joint arthroplasty in human immunodeficiency virus-positive patients: an
3. Crockarell, J. R.; Hanssen, A. D.; Osmon, D. R.; and Morrey, B. F.: Treatment of alarming rate of early failure. J Arthroplasty, 18(3): 259-64, 2003.
infection with debridement and retention of the components following hip 15. Patel, R.; Osmon, D. R.; and Hanssen, A. D.: The diagnosis of prosthetic joint
arthroplasty. J Bone Joint Surg Am, 80(9): 1306-13, 1998. infection: current techniques and emerging technologies. Clin Orthop Relat Res,
4. Di Cesare, P. E.; Chang, E.; Preston, C. F.; and Liu, C. J.: Serum interleukin-6 as a (437): 55-8, 2005.
marker of periprosthetic infection following total hip and knee arthroplasty. J 16. Sanchez-Ballester, J.; Smith, M.; Hassan, K.; Kershaw, S.; Elsworth, C. S.; and
Bone Joint Surg Am, 87(9): 1921-7, 2005. Jacobs, L.: Wound infection in the management of hip fractures: a comparison
5. Gusenoff, J. A.; Hungerford, D. S.; Orlando, J. C.; and Nahabedian, M. Y.: between low-molecular weight heparin and mechanical prophylaxis. Acta
Outcome and management of infected wounds after total hip arthroplasty. Ann Orthop Belg, 71(1): 55-9, 2005.
Plast Surg, 49(6): 587-92, 2002. 17. Sankar, B.; Hopgood, P.; and Bell, K. M.: The role of MRSA screening in joint-
6. Hanssen, A. D., and Osmon, D. R.: The use of prophylactic antimicrobial agents replacement surgery. Int Orthop, 29(3): 160-3, 2005.
during and after hip arthroplasty. Clin Orthop Relat Res, (369): 124-38, 1999. 18. Senneville, E.; Savage, C.; Nallet, I.; Yazdanpanah, Y.; Giraud, F.; Migaud, H.;
7. Hanssen, A. D.; Osmon, D. R.; and Nelson, C. L.: Prevention of deep peripros- Dubreuil, L.; Courcol, R.; and Mouton, Y.: Improved aero-anaerobe recovery
thetic joint infection. Instr Course Lect, 46: 555-67, 1997. from infected prosthetic joint samples taken from 72 patients and collected
intraoperatively in Rosenow's broth. Acta Orthop, 77(1): 120-4, 2006.
8. Huenger, F.; Schmachtenberg, A.; Haefner, H.; Zolldann, D.; Nowicki, K.; Wirtz,
D. C.; Blasius, K.; Lutticken, R.; and Lemmen, S. W.: Evaluation of postdischarge 19. Tattevin, P.; Cremieux, A. C.; Pottier, P.; Huten, D.; and Carbon, C.: Prosthetic
surveillance of surgical site infections after total hip and knee arthroplasty. Am J joint infection: when can prosthesis salvage be considered? Clin Infect Dis,
Infect Control, 33(8): 455-62, 2005. 29(2): 292-5, 1999.

9. Iorio, R.; Whang, W.; Healy, W. L.; Patch, D. A.; Najibi, S.; and Appleby, D.: The 20. Tsukayama, D. T.; Estrada, R.; and Gustilo, R. B.: Infection after total hip arthro-
utility of bladder catheterization in total hip arthroplasty. Clin Orthop Relat Res, plasty. A study of the treatment of one hundred and six infections. J Bone Joint
(432): 148-52, 2005. Surg Am, 78(4): 512-23, 1996.

10. Kingston, R.; Kiely, P.; and McElwain, J. P.: Antibiotic prophylaxis for dental or uro- 21. Zorrilla, P.; Gomez, L. A.; Salido, J. A.; Silva, A.; and Lopez-Alonso, A.: Low serum
logical procedures following hip or knee replacement. J Infect, 45(4): 243-5, 2002. zinc level as a predictive factor of delayed wound healing in total hip replace-
ment. Wound Repair Regen, 14(2): 119-22, 2006.
11. Krasin, E.; Goldwirth, M.; Hemo, Y.; Gold, A.; Herling, G.; and Otremski, I.:
Could irrigation, debridement and antibiotic therapy cure an infection of a total
hip arthroplasty? J Hosp Infect, 47(3): 235-8, 2001.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
28 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 29

NERVE AND VASCULAR INJURIES ASSOCIATED WITH TOTAL

HIP ARTHROPLASTY
Thomas P. Schmalzried, MD

NERVE INJURY were lengthened more than 2 cm. Only one single case of sciat-
ic nerve palsy occurred as a result of laceration during a primary

SYMPOSIA AR HIP
Prevalence of Nerve Palsy Associated with Total Hip
total hip replacement. Other reports have not found a significant
Replacement;
correlation between limb lengthening and nerve palsies. These
An analysis of 34,335 total hip replacements (primary and revi-
results suggest caution when attributing nerve palsy to excessive
sion surgeries) identified a total of 359 nerve palsies for an over-
tension from limb lengthening. Unfortunately, there are no
all prevalence of 1%. The lowest prevalence of nerve palsy
guidelines that enable the surgeon to predict the amount of
reported was 0.08% (1 palsy in 1287 cases), whereas the high-
lengthening that can be achieved safely.
est reported prevalence was 7.5% (5 palsies in 66 revision
cases). The overall prevalence of nerve palsy in primary total hip Significant bleeding with the development of a wound
replacement was 0.9% and 2.6% in revision surgery. Patients hematoma and neuropathy has been reported as many as 3
undergoing revision surgery are at nearly a three-fold risk for weeks following total hip replacement. The bleeding episodes
nerve injury. are almost universally associated with anticoagulation. This is
not surprising, however, since most patients undergoing total
The overall prevalence of nerve palsy associated with total hip
hip replacement receive some form of anticoagulation and the
replacement was 0.77% in male patients and 1.5% in female
bleeding may occur even though the anticoagulation therapy
patients. Female patients are at a nearly two-fold risk for nerve
has been administered properly.
palsy associated with total hip replacement. This analysis does
not adjust for potential confounding variables such as the etiol- A clinically significant wound hematoma usually presents as
ogy of hip disease (i.e., developmental dysplasia) and does not increasing buttock and/or thigh pain. Nerve palsy may not be
adjust for any differences in the prevalence of primary and revi- initially apparent but may develop over 12 to 24 hours. Patients
sion surgery in males and females. with buttock and or thigh pain associated with a hematoma
should be monitored for systemic signs of crush syndrome. In
The prevalence of nerve palsy in association with total hip
addition to compromising the sciatic nerve, pressure from the
arthroplasty for developmental dysplasia has been reported at
hematoma may disrupt circulation to the muscles of the gluteal
5.2%. Limb lengthening appears to only partially account for
compartment resulting in rhabdomyolysis, myoglobinuria and
this increased prevalence. Even in cases without significant limb
decreased renal function.
lengthening, the prevalence of nerve palsy was still nearly dou-
ble the prevalence in patients with osteoarthritis. True peroneal palsy can occur in association with total hip
replacement. Initial neurologic function may be clinically nor-
The sciatic nerve or its peroneal division is the most frequently
mal. The onset of neurologic dysfunction may be 3 to 5 days
injured accounting for 79% of all nerve palsies. Isolated femoral
postoperative and associated with tight bandages and/or other
palsies accounted for only 13% of nerve injuries whereas obtu-
compression of the peroneal nerve at the level of the fibular
rator palsies accounted for only 1.6%. Simultaneous injury to
neck. These cases generally respond well to the removal of the
both the sciatic and femoral nerves represented 5.8% of the
offending agent and generally have good function at 6 months.
nerve injuries in one report.
In the majority of cases, the cause of the nerve palsy is really not
Origin of Nerve Palsy Associated with Total Hip known and is the subject of speculation. The most common sce-
Replacement: nario is that of an apparently uncomplicated total hip replace-
Injury to the sciatic nerve or the peroneal division of the sciatic ment procedure in which the patient awakens from surgery with
nerve generally occur proximally at the level of the hip joint. a loss of sensory or motor function, or both, in the surgically
Electromyography has demonstrated evidence of nerve injury in treated extremity.
70% of extremities following total hip replacement; although
frank neuropathy is rare, subclinical injury is common. Physical The Role of Surgical Approach:
examination underestimates the occurrence of nerve injury Femoral nerve injuries are more frequent with an anterolateral
associated with total hip replacement. approach. Anatomic studies showed the proximity of the
femoral nerve to the anterior aspect of the hip joint and the rel-
During complex limb reconstructive procedures, such as total
ative vulnerability of the nerve to anterior acetabular retractors.
hip replacement, trauma to major peripheral nerves can occur
The lateral or anterolateral approaches may compromise the
in numerous ways. Recognizing the sensitivity of peripheral
superior gluteal nerve. This may result in abductor weakness and
nerves to compression, potential sources of direct trauma
a positive Trendelenberg sign or gait.
include surgical retractors, sutures, wires, bone grafts and the
prosthetic devices, as well as alterations in bony and/or soft tis- Electromyographic studies of patients operated through the
sue anatomy which result from the reconstructive procedure. direct lateral approach demonstrated that 23% had some dam-
Intraoperative monitoring of somatosensory cortical evoked age to the superior gluteal nerve. Fifty-two per cent of the
potentials has implicated the positioning of the limb and the patients operated through either a direct lateral or a
placement of retractors in injury of the nerve. transtrochanteric approach demonstrated an abnormal elec-
tromyogram postoperatively with evidence of recent injury.
In 1,152 consecutive primary total hip replacements, limb
Forty-four per cent of the patients had an abnormal elec-
lengthening ranged from 0.4 - 4.0 cm. In 135 revisions, limb
tromyogam preoperatively with signs of chronic denervation or
lengthening ranged from 0.04 to 5.8 centimeters. Sixty-six hips
re-innervation. Pre- and postoperative clinical tests of the hip
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
29
SYM 07:Layout 1 1/12/07 11:39 AM Page 30

abductors did not correlate with the electromyographic find- As soon as the diagnosis is established and the patient's condi-
ings. Factors other than surgical injury to the superior gluteal tion allows, a thorough discussion with the patient regarding
nerve can contribute to an insufficiency of the hip abductors. the nerve injury is recommended. An educated patient is the
best ally in maximizing recovery. The nursing staff and thera-
Based on anatomic dissections, it is generally accepted that a so-
pists should be advised of the nerve injury and additional exer-
called safe zone for the superior gluteal nerve is approximately
cises prescribed to strengthen weakened muscles and stretch
5 cm wide extending up from tip of the greater trochanter. If this
uninjured antagonists to prevent joint contracture. The patient
distance is not exceeded by intramuscular incision, the risk of
should be fitted with appropriate orthotics as soon as possible
injury to the superior gluteal nerve should be low. In clinical
in order to allow physical therapy to proceed. A knee immobi-
practice, this appears to be an adequate guideline.
SYMPOSIA AR HIP

lizer or similar removable brace to hold the knee in extension

will allow safe ambulation in the presence of a femoral neu-
Intraoperative Monitoring:
ropathy. An ankle-foot orthosis (AFO) can facilitate ambulation
Several studies have failed to clearly document that intraopera-
in patients with sciatic neuropathy. The patient should learn to
tive cortical somatosensory evoked potential monitoring of sci-
examine sensory impaired skin regions daily. If dysesthesias are
atic nerve function during total hip replacement reduces the
present, treatment with a tricyclic antidepressant or tetracyclic
prevalence of nerve palsy. The advantage of spontaneous elec-
antidepressant may be of some benefit although associated
tromyography over cortical somatosensory evoked potentials is
orthostatic hypotension or other anticholinergic side effects
that spontaneous electromyography records moment by
may outweigh the benefits in some patients.
moment muscle activity allowing immediate corrective action
to be taken, whereas cortical somatosensory evoked potentials There are no absolute indications for reoperation (exploration)
record an averaged impulse over a defined time interval. and only anecdotal experience. Good outcomes have been
Spontaneous electromyography is more specific to certain kinds reported with conservative management. With input from the
of trauma, such as direct trauma with cautery, but not sensitive patient, the physician must weigh all the variables and individ-
to changes with time, such as stretching. The efficacy of this ualize treatment based on the overall clinical condition of the
technique has not been conclusively established. patient and the relative risks and benefits of a reoperation in
each specific case.
Treatment:
If a neuropathy is discovered, a formal neurology consultation is Outcomes:
helpful. The neurologist can validate the physical findings, assist For a nerve palsy associated with total hip replacement, about
in localization of the nerve injury (often through electrodiag- 41% of reported cases recover complete, or essentially complete,
nosic studies) and assist in identifying any treatable causes of nerve function whereas 44% have a mild persistent deficit.
peripheral neuropathy. A thorough electrodiagnosic evaluation Unfortunately, about 15% of patients have a poor outcome
includes recording from the short head of the biceps. This is the characterized by weakness that limits ambulation and/or per-
only muscle in the thigh to receive innervation from the per- sistent dysesthesias. All patients who had complete recovery of
oneal division of the sciatic nerve. Denervation of this muscle function had it by 2 years. The prognosis for neurologic recov-
indicates nerve injury in the proximal thigh for what may other- ery was related to the degree of nerve damage. All patients who
wise appear to be a peroneal nerve injury at or below the knee. retained some motor function immediately after the operation,
or recovered some motor function within about two weeks of
The author is unaware of published reports of imaging studies
surgery (indicative of a lesser degree of nerve injury), made a
such as computed tomography or magnet resonance imaging
good recovery. None of the five patients with severe dysesthesia
for the localization of nerve injury, either acutely or subacutely,
had a good recovery.
after total hip replacement. In the author`s experience, these
modalities can detect hematoma formation and localized com- Although the author is unaware of any study directly comparing
pression, as well as localized swelling of a major nerve. It is rea- outcome based on the nerve(s) injured, the author`s experience
sonable to consider such modalities in the search for a treatable is a better prognosis for femoral nerve injuries. This difference
cause of a neuropathy. However, there is insufficient experience in outcome may be related to the fact that the distance that the
to determine the impact of these imaging studies on treatment nerve must regenerate to reach the motor end plates is substan-
and outcome. tially less for the femoral nerve than for the sciatic nerve. Thus,
the rate of successful reinnervation after high-grade injuries is
Coexisting spinal stenosis may be a risk factor for nerve palsy
likely to be better for the femoral nerve than for the sciatic.
associated with total hip replacement. In one report, 21 patients
with spinal stenosis developed a foot drop after total hip
VASCULAR INJURIES
replacement. These patients had a history of back and leg pain
without weakness before hip replacement. Spinal imaging stud- Occurrence:
ies demonstrated high-grade spinal stenosis in each case. Sixteen Vascular injuries associated with total hip arthroplasty are a rare
patients were treated by lumbar decompression. Twelve patients complication with an incidence of less than 0.3%. Risk factors
improved; six had complete recovery. None of the patients who for vascular injuries include revision surgery, intrapelvic migra-
did not have surgery improved. tion of the acetabular component, infection, left-sided surgery,
and female gender. Acute injuries may present as bleeding dur-
Worsening mechanical impairment of sciatic nerve function
ing surgery, delayed complications include postoperative hem-
may be lessened in the acute stage by keeping the hip extended
orrhage or hematoma, ischemia due to arterial occlusion,
and the knee flexed over the side of the bed to reduce tension in
embolism, thrombosis, false aneurysm, or arteriovenous fistula.
the nerve. The opposite position would be desirable for femoral
The patient may demonstrate symptoms related to those com-
neuropathy. Minimizing edema is of theoretical benefit but
plications such as cardiovascular reactions due to blood loss,
there is no scientific basis or documented efficacy for the use of
pain due to ischemia or pressure from a false aneurysm.
steroids or osmotic agents in this circumstance. Treatment of
any coexisting causes of peripheral neuropathy would theoreti-
cally be beneficial.
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
30 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 31

Vessels at Risk: Diagnosis:

The extrapelvic structures at risk mainly involve the common Retroperitoneal or intra-pelvic bleeding is usually not visually
femoral vessels, the profundus femoral vessels and their branch- apparent in the field of dissection for the arthroplasty. Intra-
es, the medial and lateral circumflex arteries. Blunt damage from pelvic bleeding from a major vessel should be high in the dif-
retractor placement and intraoperative retraction appear to be ferential diagnosis of an acute, sustained drop in blood pressure
the main causes for the damage of those vessels, especially during total hip arthroplasty.
retractors placed around the anterior rim of the acetabulum
(femoral artery and vein) and around the femoral neck (medial Treatment :
and lateral circumflex artery). An immediate request for a vascular or general surgeon should

SYMPOSIA AR HIP
be made. Most orthopaedic surgeons do not have expertise in
The external lilac artery and vein, the obturator vein and artery,
the management of a major arterial injury, so the practical goal
and the inferior gluteal vessels are the intrapelvic vascular struc-
for the orthopaedist is to reduce the acute bleeding. In the oper-
tures that are at risk during hip athroplasty. The external iliac
ating room, temporizing methods include packing-off of the
vessels and the obturator vessels can be damaged by anterior
bleeding vessel from the remainder of the wound, or placing a
and inferior retractors or by the removal of a medially migrated
clamp around the surrounding tissue, if not on the actual vessel
acetabular component. With the use of screws for fixation of
or lumen. Prompt, adequate volume replacement can prevent
cementless implants and revision cages, the most common
vascular collapse. A laparotomy may be necessary to control life-
injury mechanism is intrapelvic screw placement.
threatening retro-peritoneal or intra-pelvic bleeding by applying
The quadrant system was introduced to help the surgeon with direct pressure to the source of bleeding. Arterial bleeding can
intraoperative orientation of safe zones for screw placement. be reduced by pressure to the aorta (below the renal arteries) or
The acetabulum is divided into anterior and posterior halves by on the iliac artery. Localized packing of venous bleeding, with or
a line originating from the anterior superior iliac spine. A per- without thrombostatic agents, can reduce acute blood loss.
pendicular line divides each half into a superior and inferior Embolization can stop retro-peritoneal or intra-pelvic bleeding,
quadrant. The intrapelvic structures adjacent to the anterior given the availability of this modality and that the patient is sta-
quadrants include the external iliac vessels and the obturator ble enough to be transferred to an angiography suite.
vessels. Located opposite to the posterior inferior quadrant are
the inferior gluteal and the internal pudendal vessels. The pos-
terior superior quadrant is considered the safest zone for screw
placement because it consists of the highest bone depth for
secure screw fixation. It should be recognized that the superior
gluteal vessels are located beyond this quadrant.

RECOMMENDED READING 4. Lewallen DG. Neurovascular injury associated with hip arthroplasty. Instr Course
1. Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with Lect. 1998;47:275-83.
total hip replacement. Clin Orthop. 1997;344:188-206. 3. Barrack RL, Butler RA. Avoidance and management of neurovascular injuries in
total hip arthroplasty. Instr Course Lect. 2003;52:267-74.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
31
SYM 07:Layout 1 1/12/07 11:39 AM Page 32

HETEROTOPIC OSSIFICATION
Vincent D. Pellegrini, Jr, MD

I. Pathophysiology f. CNS disorders (Parkinson’s disease, periop CVA,

A. Common link – injury (surgical or natural) to the abduc- SCI)
tor musculature 3. Elevation of spinal bone mineral density
B. Pluripotential mesenchymal stem cell differentiation
IV.Prophylaxis
SYMPOSIA AR HIP

1. Onset of cellular differentiation within 16 hours of

A. Effective prophylaxis must begin within 4-5 days of oper-
injury
ation
2. Peak approximately 32 hours after inciting event
B. Bisphosphonates – of historical interest
C. Local vs. Distant origin of cells
1. Delay mineralization of osteoid matrix
1. Local
2. Appearance of HO proceeds after discontinuation of
a. "Bone dust" - as nidus for bone growth
the drug
b. Perivascular connective tissue in epimysium
C. NSAIDs - ibuprofen, indomethacin (25 mg TID x 7 – 10
2. Distant
days)
a. Migratory hematopoietic stem cells
1. Systemic action - no localized effects
b. Adjacent intramedullary marrow cavity
a. Interference (laboratory) with biologic fixation of
c. Blood borne in the local hematoma
implants
D. Cartilage model (endochondral) bone formation path-
2. Poor GI intolerance in 30-50% of arthroplasty
way
patients
1. Metabolically hyperactive tissue
3. Interference with TED prophylaxis with anticoagulants
2. 2x number of active osteocytes; 3x width of osteoid
D. Radiation - immediate preop (6 hrs) or early postop (4
seam
days) – 700 - 800 cGy
II. Radiographic Staging 1. Localized action – precision delivery - <5% dose Rx at
A. Brooker (Stage) 1 cm outside portal
1. I – Islands of bone in the soft tissues a. Limited field - avoids interference with implant fix-
2. II – Bone spurs arising from pelvis or femur with ation
>1cm between surfaces 2. Single dose - excellent compliance with regimen
3. III - Bone spurs arising from pelvis or femur with 3. No local wound complications
<1cm between surfaces 4. Trochanteric nonunion risk – if poor fixation / revi-
4. IV - Confluent bone bridging pelvis and femur; appar- sion setting
ent bony ankylosis 5. Late oncogenic risk - none reported with less than
B. Rochester (Grade) 3000 cGy dose
1. A – < 1/3 of area between greater trochanter, ASIS,
V. Treatment
inferior ischium
A. THA ankylosis
2. B – 1/3 to 2/3 area between greater trochanter, ASIS,
1. Surgical resection of HO
inferior ischium
a. Conventional wisdom – 2 years or wait for a cold
3. C - > 1/3 of area between greater trochanter, ASIS,
Tech99 scan
inferior ischium
b. Sooner removal under cover of prophylaxis - radia-
III. Clinical Scenario and Prevalence … about the hip tion
A. THA, acetabular fx, pelvic osteotomy, IM nailing femur fx 2. Imaging for staging and preoperative planning
1. THA – up to 90% radiographic prevalence a. Location of hardware and planned removal vs.
a. Clinically significant – 8-10% Brooker III and IV retention
i. Pain – early - during active inflammatory stages b. Judet views of pelvis – anterior or posterior bridg-
ii. Stiffness - loss of ROM due to bulk of HO or ing bone
bony ankylosis c. CT scan - displacement of adjacent neurovascular
iii.Pain – late - secondary soft tissue inflammation, structures
bursitis 3. Intraoperative considerations
B. Associated clinical conditions a. Blunt dissection – fibrous tissue plane adjacent to
1. Operative approach to the hip HO
Transgluteal (Hardinge) > Trans-trochanteric > b. Excessive blood loss – bleeding bony surfaces
Watson-Jones > Kocher c. Formal sciatic neurolysis (with loupes) with hx of
2. Associated clinical conditions deficit
a. Ankylosing spondylitis 4. Postoperative management
b. Hypertrophic osteoarthritis a. Expanded full field RT - 800 cGy – within 3-4 days
c. Diffuse Skeletal Hyperostosis (DISH) b. Biphasic recovery of motion - transient stiffness sec-
d. Prior HO after hip surgery ondary to fibrosis
e. Male gender c. Gluteal abductor weakness – proportional to
amount of bone resection

REFERENCES 2. Brooker, A.F., Bowerman, J.W., Robinson, R.A., Riley, L.H., Jr.: Ectopic ossifica-
1. Bonarigo, B.C., Rubin, P.: Nonunion of pathologic fracture after radiation thera- tion following total hip replacement. Incidence and a method of classification. J
py. Radiology 88:889-898, 1967. Bone Joint Surg 55A:1629-1632, 1973.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
32 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 33

3. Cella, J.P., Salvati, E.A., Sculco, T.P.: Indomethacin for the prevention of hetero- 11. Pellegrini, V.D., Jr., Konski, A.A., Gastel, J.A., et al: Prevention of heterotopic ossi-
topic ossification following total hip arthroplasty. Effectiveness, contraindica- fication with irradiation after total hip arthroplasty. Radiation with a single dose
tions, and adverse effects. J Arthrop 3:229-234, 1988. of 800 cGy administered to a limited field. J Bone Joint Surg 74A:186-200, 1992.
4. Chalmers J, Gray DH, Rush J. Observations on the induction of bone in soft tis- 12. Pellegrini, V.D., Jr.: Heterotopic Ossification after Total Hip Arthroplasty. In:
sues. J Bone Joint Surg Br. 1975;57:36-45. Advanced Adult Reconstruction of the Hip. Berry, D. and Lieberman, J., Editors.
5. Cobb TK, Berry DJ, Wallrichs SL, Ilstrup DM, Morrey BF. Functional outcome of AAOS Publishing, Chicago. 2005.
excision of heterotopic ossification after total hip arthroplasty. Clin Orthop. 13. Pellegrini, V.D., Jr.: Heterotopic Ossification. In : Revision Total Hip and Knee
1999;361:131-9. Arthroplasty. Berry, D., Trousdale, R., Dennis, D., and Paprosky, W., Editors.
6. DeLee, J., Ferrari, A., Charnley, J: Ectopic bone formation following low friction Lippincott, Williams, and Wilkins, Philadelphia. In Press, 2006.
arthroplasty of the hip. Clin Orthop 121:53-59, 1976. 14. Rumi, M.N., Deol, G.S., Singapuri, K., Pellegrini, V.D., Jr.: The Origin of

SYMPOSIA AR HIP
7. Furia, J.P., Pellegrini, V.D., Jr.: Heterotopic ossification following primary total Osteoprogenitor Cells Responsible for Heterotopic Ossification Following Hip
knee arthroplasty. J Arthrop 10(4):1-7, 1995. Surgery: An Animal Model in the Rabbit. J Orthopaedic Research 2005;23(1):
34-40.
8. Pellegrini, V.D., Jr.: Radiation Prophylaxis of Heterotopic Ossification. Int J Rad
Oncol 30(3):743-744, October, 1994. 15. Rumi, M.N., Deol, G.S., Bergandi, J., Singapuri, K., Pellegrini, V.D., Jr.: Optimal
Timing of Preoperative Radiation for Prophylaxis Against Heterotopic
9. Pellegrini, V.D., Jr., Evarts, C.M.: Radiation prophylaxis of heterotopic bone for- Ossification. A Rabbit Hip Model. J Bone and Joint Surgery Am. 2005;87(2):
mation following total hip arthroplasty: Current status. Semin Arthrop 3:156- 366-373.
166, 1992.
16. Schneider, D.J., Moulton, M.J., Singapuri, K., Chinchilli, V., Deol, G.S., Krenitsky,
10. Pellegrini, V.D., Jr., Gregoritch, S.J.: Preoperative Irradiation for Prevention of G., Pellegrini, V.D., Jr.: The Frank Stinchfield Award: Inhibition of Heterotopic
Heterotopic Ossification Following Total Hip Arthroplasty. J Bone Joint Surg Ossification with Radiation Therapy in an Animal Model. Clin Orthop and Rel
78A(6):870-881, June, 1996. Res (355):35-46, October, 1998.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
33
SYM 07:Layout 1 1/12/07 11:39 AM Page 34

MULTIMODAL PROPHYLAXIS
Eduardo A. Salvati, MD

The etiology of venous thromboembolism (VTE) following Using this multimodal prophylaxis, our prevalence of sympto-
THA is multifactorial.1 Thus, the prophylaxis should be multi- matic DVT and PE is low.2 In our most recent prospective evalua-
modal.2 Traditional emphasis has been placed mainly on post- tion comprising 1769 consecutive patients (1854 THAs) operat-
operative prophylaxis (anticoagulants3,4 and/or intermittent ed between 1994 and 2003, and followed for a minimum of 3
SYMPOSIA AR HIP

pneumatic compression5-9). Recognized clinical predisposing months after surgery, 25 patients (1.4%) developed a sympto-
factors are listed according to their severity: malignancy, partic- matic proximal DVT and 10 (0.6%) a symptomatic PE (none
ularly if associated with chemotherapy; antiphospholipid syn- fatal).2 Seventeen of these 35 patients (48.6%) had no recognized
drome, immobility, history of venous thromboembolism; clinical predisposing factors, a finding also reported by Ferrari et
administration of tamoxifen, raloxifene, oral contraceptives or al,31 which led us to study the presence of heritable thrombophil-
estrogen; morbid obesity, stroke, atherosclerosis, and an ia and hypofibrinolysis in patients who develop VTE.
American Society of Anesthesiologists physical status classifica-
The results of our study of heritable thrombophilia and
tion of 3 or greater10-13). In this presentation I will highlight our
hypofibrinolysis32,33 and those of others,34-36 have defined the
multimodal prophylaxis we implement prior, during and after
major genetic predispositions which increase the risk of throm-
surgery to prevent or minimize the formation and propagation
boembolism (antithrombin III (<75%), protein C deficiency
of venous thrombosis, and the rationale for its use.2
(<70%), and homo-heterozygosity for the prothrombin gene
Our multimodal prophylaxis includes: preoperative discontinu- mutation).33 Pre-operative screening for these genetic predispo-
ation of procoagulant medications, autologous blood dona- sitions, along with the recognized clinical comorbidities previ-
tion,14 hypotensive epidural anesthesia,15,16 intraoperative intra- ously mentioned, differentiate patients who need mild prophy-
venous heparin (10U/kg) administered prior to femoral prepa- laxis with those at higher risk who need to be anticoagulated
ration when the clotting cascade is maximally activated,17-20 more aggressively.
expedient surgery minimizing femoral vein occlusion and
During the last decade, more potent anticoagulants have been
blood loss,21-22 frequent lavage and aspiration of intramedullary
advocated as a sole method of prophylaxis.37 An aggressive mar-
contents during femoral preparation to reduce the venous load
keting program, including sponsored publications and courses,
of procoagulants,1,23 preheating the femoral component to 40-
has contributed to their initial popularity. However, the risk of
45º C to reduce the duration of cement polymerization by ± 5
hemorrhagic complications exceeded that of aspirin and war-
minutes,24,25 immediate postoperative intermittent pneumatic
farin.38,39,40 In addition, severe thrombocytopenia develops in
compression,5-9 elastic stockings,26 early mobilization (empha-
approximately 1% of patients receiving heparin for more than
sizing repeated and vigorous active dorsiflexion of ankles which
four days. Successful therapy requires immediate cessation of
increases 50% femoral venous blood flow27), aspirin in 83% of
heparin and if not promptly recognized antibody-mediated
patients, and warfarin in the remaining 17% (those with pre-
thrombocytopenia carries a 40% mortality.41 Anticoagulation-
disposing factors or who were on it prior to surgery).2 If these
induced persistent wound drainage and hematoma are associ-
preventive measures are closely followed the postoperative
ated with a significantly higher prevalence of wound infection.42
chemoprophylaxis does not need to be aggressive in the patient
These concerns prompted leaders in joint replacement surgery
who has no predisposing factors and who mobilizes promptly.
to publish a recent editorial recommending caution in the
From the mid 1970's, enteric-coated aspirin has been our pre- extensive use of potent anticoagulants.38
ferred postoperative chemoprophylaxis for patients with no
We conducted a meta-analysis of the English literature pub-
additional predisposing factors for VTE. Aspirin prophylaxis is
lished from 1996 to 2006 to determine whether potent antico-
safe, inexpensive, well-tolerated easy-to-administer, requires no
agulants (low molecular weight heparin, ximelagatran, fonda-
monitoring, has analgesic and antipyretic effects and reduces
parinux or BAY 59-7939) confer any benefit on mortality after
the risk of ectopic ossification.2,28 Aspirin also reduces the risk of
total hip and knee arthroplasty. The meta-analysis showed that
arterial complications including unstable angina, cerebrovascu-
potent anticoagulation administered to 13,380 patients did not
lar accidents and transient ischemic attacks. Two recent studies
prevent pulmonary embolism (0.64%) and was associated with
demonstrated that the most frequent cause of death was
the highest mortality (0.47%). The multimodal approach
ischemic heart disease, which supports the use of aspirin pro-
(regional anesthesia, pneumatic compression and aspirin)
phylaxis in view of its beneficial arterial effects. Both studies
applied to 7,193 patients was associated with a lower rate of
employed mechanical thromboprophylaxis and the patients
pulmonary embolism (0.35% p=0.009) and with the lowest all-
were followed for 3 months. One of these studies followed 2153
cause mortality (0.19% p=0.003) while Coumadin was associ-
THR and TKR; of the eight autopsy proven deaths five (62.5%)
ated with an intermediate mortality (0.41%).43
were due to ischemic heart disease.29 The other study followed
1727 THR; there were 7 (0.41%) deaths due to ischemic heart In summary, we recommend that the prophylaxis of VTE should
disease, 4 (0.23%) due to cerebrovascular events and 2 (0.12%) be multimodal including the pre, intra and postoperative meas-
due to pulmonary embolism. Four (0.23%) other patients died ures previously outlined to minimize its multifactorial etiology.
of non-vascular causes.30 If the surgeon ignores these perioperative prophylactic measures
the postoperative prophylaxis will have to be more aggressive
with an increased risk of bleeding complications.

REFERENCES 2. Gonzalez Della Valle A, Serota A, Go G, Sorriaux G. Sculco T, Sharrock N, Salvati

1. Salvati EA, Pellegrini VD, Jr., Sharrock NE, Lotke PA, Murray DW, Potter H, E: Venous thromboembolism is rare after THR with a multimodal prophylaxis
Westrich GH. Recent advances in venous thromboembolic prophylaxis during protocol. Clin Orthop 444:146-153, March 2006.
and after total hip replacement. J Bone Joint Surg Am 2000;82-2:252-70.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
34 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 35

3. Imperiale TF, Speroff T: A meta-analysis of methods to prevent venous throm- 25. Iesaka K, Jaffe WL, Kummer FJ: Effects of preheating of hip prostheses on the
boembolism following total hip replacement. Jama 1994; 271: 1780-5. stem-cement interface. J Bone Joint Surg Am 2003; 85-A: 421-7.
4. Lieberman JR, Wollaeger J, Dorey F, et al.: The efficacy of prophylaxis with low- 26. Prandoni P, Lensing AW, Prins MH, Frulla M, Marchiori A, Bernardi E, Tormene
dose warfarin for prevention of pulmonary embolism following total hip arthro- D, Mosena L, Pagnan A, Girolami A. Belowknee.Elastic compression stockings to
plasty. J Bone Joint Surg Am 1997; 79: 319-25 prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann
5. Lachiewicz PF, Soileau ES: Multimodal prophylaxis for THA with mechanical Intern Med. 2004;141:249–256.
prophylaxis. Clin Orthop 2006-Sep 21 27. Markel, D, Urquhart, B, Derkowska, I., Salvati, EA, Sharrock, N: Effect of epidural
6. Macaulay W, Westrich G, Sharrock N, Sculco TP, Jhon PH, Peterson MG, Salvati analgesia on venous blood flow after hip arthroplasty. Clin Orthop. 334:168-
EA. Effect of pneumatic compression on fibrinolysis after total hip arthroplasty. 174, 1997.
Clin Orthop 2002-399:168-76. 28. Pagnani MJ, Pellicci PM, Salvati EA: Effect of aspirin on heterotopic ossification

SYMPOSIA AR HIP
7. Ryan MG, Westrich GH, Potter HG, Sharrock N, Maun LM, Macaulay W, Katkin after total hip arthroplasty in men who have osteoarthrosis. J Bone Joint Surg
P, Sculco TP, Salvati EA. Effect of mechanical compression on proximal deep Am. 1991,73:924-929.
venous thrombosis by magnetic resonance venography. J Bone Joint Surg Am 29. Shepherd A and Mills C. Fatal pulmonary embolism following hip and knee
2002;84-A-11:1998-2004. replacement. A study of 2153 cases using routine mechanical prophylaxis and
8. Westrich GH, Specht LM, Sharrock NE, Sculco TP, Salvati EA, Pellicci PM, selective chemoprophylaxis. Hip International Vol. 16 Jan-March 2006.
Trombley JF, Peterson M. Pneumatic compression hemodynamics in total hip 30. Blom A, Pattison G, Whitehouse S, Taylor A, et al: Early death following primary
arthroplasty. Clin Orthop 2000-372:180-91. total hip arthroplasty. Acta Orthopaedica. 2006; 77 . 3:347-350.
9. Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J. Mechanical prophylaxis of deep- 31. Ferrari B, Baudouy M, Cerboni P: Clinical epidemiology of venous thromboem-
vein thrombosis after total hip replacement a randomised clinical trial. J Bone bolic disease. Results of a French multicenter registry. Eur Heart J 1997; 18: 681-
Joint Surg Br 2004;86-5:639-42.. 691.
10. Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Risk factors for 32. Westrich GH, Weksler BB, Glueck CJ, Blumenthal BF, Salvati EA. Correlation of
clinically relevant pulmonary embolism and deep venous thrombosis in patients thrombophilia and hypofibrinolysis with pulmonary embolism following total
undergoing primary hip or knee arthroplasty. Anesthesiology 2003;99-3:552-60; hip arthroplasty: an analysis of genetic factors. J Bone Joint Surg Am 2002;84-A-
discussion 5A. 12:2161-7.
11. Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Frequency of 33. Salvati EA, González Della Valle A, Westrich GH, Rana AJ, Specht L, Weksler BB,
myocardial infarction, pulmonary embolism, deep venous thrombosis, and Wang P, Glueck CJ “Heritable thrombophilia and development of thromboem-
death following primary hip or knee arthroplasty. Anesthesiology 2002;96- bolic disease following total hip arthroplasty” -THE CHARNLEY HIP SOCIETY
5:1140-6. AWARD. Clin. Orthop. Dec. 2005
12. White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehos- 34. Mont MA, Jones LC, Rajadhyaksha AD, Shuler MS, Hungerford DS, Sieve-Smith
pitalization for symptomatic venous thromboembolism after total hip arthro- L, Wang P, Cordista AG, Glueck CJ. Risk factors for pulmonary emboli after total
plasty. N Engl J Med 2000;343-24:1758-64. hip or knee arthroplasty. Clin Orthop 2004-422:154-63.
13. Beksac B, Gonzalez Della Valle A, Salvati EA: Thromboembolic Disease after 35. Lowe GD, Haverkate F, Thompson SG, Turner RM, Bertina RM, Turpie AG,
Total Hip Arthroplasty: Who is at Risk? Clin Orthop. 2006, in press Mannucci PM. Prediction of deep vein thrombosis after elective hip replacement
14. Bae H, Westrich GH, Sculco TP, Salvati EA, Reich LM. The effect of preoperative surgery by preoperative clinical and haemostatic variables: the ECAT DVT Study.
donation of autologous blood on deep-vein thrombosis after total hip arthro- European Concerted Action on Thrombosis. Thromb Haemost 1999;81-6:879-
plasty. J Bone Joint Surg Br 2001;83-5:676-9. 86.

15. Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthro- 36. Wahlander K, Larson G, Lindahl TL, Andersson C, Frison L, Gustafsson D, Bylock
plasty: a review. Acta Orthop Scand 1996;67-1:91-107. A, Eriksson BI. Factor V Leiden (G1691A) and prothrombin gene G20210A muta-
tions as potential risk factors for venous thromboembolism after total hip or
16. Westrich GH, Farrell C, Bono JV, Ranawat CS, Salvati EA, Sculco TP: The inci- total knee replacement surgery. Thromb Haemost 2002;87-4:580-5.
dence of venous thromboembolism after total hip arthroplasty: a specific
hypotensive epidural anesthesia protocol. J Arthroplasty. 1999,14:456-463. 37. Colwell CW, Jr., Berkowitz SD, Davidson BL, Lotke PA, Ginsberg JS, Lieberman
JR, Neubauer J, McElhattan JL, Peters GR, Francis CW. Comparison of ximelaga-
17. Gitel SN, Salvati EA, Wessler S, Robinson HJ, Jr., Worth MH, Jr. The effect of total tran, an oral direct thrombin inhibitor, with enoxaparin for the prevention of
hip replacement and general surgery on antithrombin III in relation to venous venous thromboembolism following total hip replacement. A randomized, dou-
thrombosis. J Bone Joint Surg Am 1979;61-5:653-6. ble-blind study. J Thromb Haemost 2003;1-10:2119-30.
18. DiGiovanni CW, Restrepo A, Gonzalez Della Valle AG, Sharrock NE, McCabe JP, 38. Callaghan JJ, Dorr LD, Engh GA, et al: Prophylaxis for thromboembolic disease. J
Sculco TP, Pellicci PM, Salvati EA. The safety and efficacy of intraoperative Arthroplasty 2005; 20 :273
heparin in total hip arthroplasty. Clin Orthop 2000-379:178-85.
39. FDA Public Health Advisory: Reports of epiudural or spinal hematomas with the
19. Sharrock NE, Go G, Harpel PC, Ranawat CS, Sculco TP, Salvati EA. The John concurrent use of low molecular weight heaprin and spinal/epidural anesthesia
Charnley Award. Thrombogenesis during total hip arthroplasty. Clin Orthop or spinal puncture. Washington, DC, U.S. Dpt. of Health and Human Resources,
1995-319:16-27. 1997
20. Westrich GH, Salvati EA, Sharrock N, Potter HG, Sanchez PM, Sculco TP: The 40. Lilikakis AK, Papapolychroniou T, Macheras G, Michelinakis E
effect of intraoperative heparin administered during total hip arthroplasty on the Thrombocytopenia and Intra-cerebral Complications Associated with Low-
incidence of proximal deep vein thrombosis assessed by magnetic resonance Molecular-Weight Heparin Treatment in Patients Undergoing Total Hip
venography. J Arthroplasty, 2005 Jan;20(1):42-50. Replacement. A Report of Two Cases. J Bone Joint Surg Am 2006;88 634-638
21. Planes A, Vochelle N, Fagola M. THR and DVT. A venographic and necropsy 41. Warkentin TE. Heparin-Induced ThrombocytopeniaT: Lessons Learned.
study. J Bone Joint Surg Br 1990;72. Pathophysiol Haemost Thromb. 2006:35(12)
22. Binns M, Pho R. Femoral vein occlusion during hip arthroplasty. Clin Orthop 42. Sanchez-Ballester J, Smith M, Hassan K, et al.: Wound infection in the manage-
1990-255:168-72. ment of hip fractures: a comparison between low-molecular weight heparin and
23. Pitto RP, Hamer H, Fabiani R, Radespiel-Troeger M, Koessler M. Prophylaxis mechanical prophylaxis. Acta Orthop Belg 2005; 71: 55-9.
against fat and bone-marrow embolism during total hip arthroplasty reduces the 43. Sharrock NE, Gonzalez Della Valle A, Go G, Salvati EA. Meta-analysis of throm-
incidence of postoperative deep-vein thrombosis J Bone Joint Surg Am 2002;84- boprophylaxis and all-cause mortality following total hip and knee arthroplasty.
A-1:39-48. JBJS A In Press
24. Parks ML, Walsh HA, Salvati EA, Li S: Effect of increasing temperature on the
properties of four bone cements. Clin Orthop. 1998,238-248.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
35
SYM 07:Layout 1 1/12/07 11:39 AM Page 36

DVT PROPHYLAXIS AFTER TOTAL HIP ARTHROPLASTY

Jay R. Lieberman, MD

I. Introduction TOTAL HIP ARTHROPLASTY – TOTAL DVT PREVALENCE

A. Goals Regimen No. Combined Total DVT Risk Prox DVT RR (%)
1. Warfarin Prophylaxis: Clinical Data Trials Enrollment Prevalence Reduction (%)
2. Duration of prophylaxis (%) (%)
SYMPOSIA AR HIP

a. Screening – Is it safe? Control 12 626 54 — 26.6 —

3. Special Cases LMWH 30 6216 16 70 5.92 78
Warfarin 13 1828 22 59 5.2 80
II. Pathogenesis and Epidemiology IPC 7 423 20 63 13.7 48
A. Etiology of thrombosis formation Aspirin 6 473 40 26 11.4 57
1. THA – potent stimulus for the formation of thrombi
2. Virchow’s Triad-venous stasis, hypercoagulability, B. Warfarin
endothelial injury 1. Properties
3. When do the thrombi form? (Sharrock et al, 1995) a. Vit K antagonist – blocks transformation of factors
a. Analysis of circulating indices of thrombosis and II, VII, IX and X.
fibrinolysis b. Advantage – Oral agent
i.) Prothrombin F1.2, thrombin–anti-thrombin c. Disadvantages
complexes, fibrinopeptide A and D – dimer i) Requires monitoring (INR 1.8 – 2.5)
b. Activation of clotting cascade during THA occurs ii) Drug interaction
during insertion of the femoral component iii) Delayed onset of action
c. Femoral venous occlusion and use of cement are 2. Cohort Studies
also factors in thrombogenesis a. Lieberman et al (UCLA experience, JBJS, 1997) –
d. TKA-significant in thrombotic indices occurs after Symptomatic P.E.
tourniquet release i) 1,099 hips – Primary – 680 hips; Revision – 419
Conclusion: Thrombi begin forming during TJA. The hips
greatest thrombogenic stimulus is preparation of the ii) PE rate – 12/1,099 – 1.1%
femoral component during THA. iii) Fatal PE rate – 1/1,099 – 0.1%
B. Epidemiology iv)Bleeding – 2% (Increased bleeding with PT
1. No Prophylaxis greater than 17 seconds
a. Overall DVT rate – 40-80% v) Recommendations – Two weeks of Warfarin
b. Proximal DVT rate – 15-25% prophylaxis safe and effective
c. Fatal Pulmonary Embolism – 0.3 – 2% b. Robinson et al (Arch Intern Med., 1997)
2. Strong association between proximal thrombosis for- i) 516 patients (Primary and Revisions)
mation and fatal pulmonary embolism ii) Symptomatic Proximal DVT – 5/506 (1.0%)
3. We are still unable to predict which patients will iii) Fatal P.E. – 0
develop symptomatic proximal clots or pulmonary iv)Bleeding episode – 7/506 (1/0%)
emboli. Therefore, all TJA patients require prophylax- Warfarin safe and effective
is. 3. LMWH versus Warfarin – A number of randomized
Note: Our goal should be to develop a prophylaxis regi- trials have compared LMWHs with Warfarin
men in our institutions that is both safe and effec- Hull (1993) – Tinzaparin
tive. There is no ideal prophylaxis regimen that is RD Heparin (1994) – Ardeparin
available today. The selection of an agent is often Francis (1997) – Dalteparin
a compromise between efficacy and safety. Colwell (1999) – Enoxaparin – Symptomatic DVT
III. Prophylaxis and Total Hip Arthroplasty (no venograms)
A. Prophylaxis Options Hull (2000)-North American Fragmin Trial
1. Goal – Prevent Symptomatic P.E. and DVT and fatal Summary – Studies of Hull et al, RD Heparin and
pulmonary embolism Francis et al noted a lower overall asymptomatic DVT
2. Pharmocologic Agents (most commonly used) rate with the LMWH compared with Warfarin but
a. Low molecular weight heparins there were higher rates of bleeding complications in
b. Warfarin patients in 2 of the studies (Hull et al and Francis et
c. Aspirin al). The symptomatic DVT rates and PE rates were not
d. Fondaparinux – New synthetic pentasaccharide significantly different. In the North American Fragmin
e. Combined modalities Trial patients received a single dose of the drug once a
3. Mechanical day. The first dose was given either 2 hours preopera-
a. Pneumatic devices tively (1/2 dose) or 4 hrs (1/2 dose) after surgery. The
b. TED stockings patients treated with the Dalteparin had significantly
c. Ambulation lower overall DVT rates (10.7% vs 13.1%) and proxi-
mal clot rates (0.8% vs 3.0%) than patients treated
with Warfarin. Patients that received preoperative
Dalteparin had increased risk of surgical site bleeding.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
36 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 37

Colwell et al (JBJS, 1999) – Symptomatic VTED – ii. Operative site bleeds – trend toward increased
LMWH vs Warfarin bleeds
1. randomized trial, 7-10 days of prophylaxis e. Both LMWHs and Warfarin provide safe and effective
2. Multi-center study (3011 patients) prophylaxis after TKA
3. LMWH associated with reduced symptomatic
WARFARIN VERSUS LOW MOLECULAR WEIGHT HEPARIN
events during period of hospitalization (LMWH- PROPHYLAXIS AFTER TOTAL KNEE ARTHROPLASTY*
0.3%; Warfarin-1.1%, p=0.00083)
4. Period after hospital discharge there was no dif- Successful DVT (%) Pulmonary
Study Population Veno- Overall Proximal Embolism Bleeding
ference in symptomatic DVT between LMWH
graphy (%) (%)

SYMPOSIA AR HIP
and the Warfarin group (3.4% versus 2.6%) Hull et al13
5. Colwell et al – Bleeding events-The difference in Warfarin 324 277 54.9 12.3 0.0 2.4
major bleeding rates did approach statistical sig- Logiparin14 317 258 45.0 7.8 0.0 4.4
nificance (p=0.055). (Authors recommended RD Heparin
monitoring platelet counts in the post-opera- Warfarin 147 147 41.0 10.0 0.0 NA
tive period). RD heparin 150 150 25.0 6.0 0.0 NA
4. Warfarin versus Pneumatic devices: (twice daily)
Hamulyak et al15
Pneumatic Devices
Warfarin 61 NA 37.7 9.8 0.0 1.3
1. Properties Nadroparine 65 NA 24.6 7.7 0.0 2.6
a) Efficacy with proximal clots is questionable with LeClerc et al12
pneumatic devices Warfarin 334 211 51.7 10.4 0.9 1.8
b) In-hospital prophylaxis only but no monitoring Enoxaparin 336 206 36.9 11.7 0.3 2.1
or bleeding Heit et al16
c) Three studies comparing PCB vs Warfarin Warfarin 279 222 38.0 7.0 0.04 4.4
demonstrated reduced overall DVT rate with Ardeparin 277 232 27.0 6.0 0.0 7.9
Fitzgerald et al17
PCB but questionable efficacy against proximal
Warfarin 176 122 45.0 11.0 0.6 3.0
clots Enoxaparin 173 108 25.0 1.7 0.0 7.0
F. Recommendations: LMWH, Warfarin and Fondaparinux
Abbreviations: DVT=deep venous thrombosis and NA=not applicable.
provide effective and safe prophylaxis after THA. Use
*Randomized trials
pneumatic devices as an adjunctive agent.
D. Conclusion: LMWH, Warfarin, pneumatic compression
IV.DVT after TKA and Fondaparinux provide safe and effective prophylaxis
A. Venous Thromboembolism - TKA versus THA after TKA.
1. Overall DVT rate - TKA > THA
2. More difficult to suppress venous thrombosis forma- V. Duration of Prophylaxis
tion in TKA patients with same agents A. The ideal duration of prophylaxis remains unknown
3. Lower rates of symptomatic PE 1. Epidemiologic study using a medicare database noted
B. Prophylaxis Options that symptomatic VTE occurred 17 days after the THA
1. Goal - Prevent symptomatic PE and DVT and 7 days after TKA (White et al)
2. Pharmacologic Options B. A number of randomized trials have assessed the need
a. Low Molecular Weight Heparins for out of hospital prophylaxis (Planes et al, 1996,
b. Warfarin Bergquist et al, 1996, Dahl, 1997, Heit et al, 2001, etc).
c. Aspirin 1. In general, used asymptomatic DVT as surrogate out-
d. Pneumatic compression devices come (21-35 days of prophylaxis).
e. Fondaparinux 2. THA patients had lower DVT rates with extended
f. Combined modalities duration prophylaxis but no difference in DVT rates in
TKA patients
TOTAL KNEE ARTHROPLASTY – TOTAL DVT PREVALENCE 3. These studies noted a substantial rate of asympto-
Regimen No. Combined Total DVT Risk Prox DVT RR (%) matic DVT formation post-discharge. LMWH seemed
Trials Enrollment Prevalence Reduction (%) to reduce this rate in THA patients
(%) (%) 4. Heit et al (2001) assessed symptomatic DVT in THA
Control 6 199 64.3 ------- 15.3 -------
and TKA patients and found no benefit with extended
LMWH 13 1740 30.6 52 5.6 63
Warfarin 9 1294 46.8 27 10.0 35
duration prophylaxis.
IPC 4 110 28.2 56 7.3 52 5. However, large cohort studies revealed low sympto-
FP 4 172 43.2 37 2.3 85 matic PE rates 90 days after discharge with Warfarin or
Aspirin 6 443 56.0 13 8.9 42 LMWH prophylaxis
(From ACCP Guidelines, Chest, 2001)
a. Lieberman et al (1,099 pts.) – 1.1%
b. Robinson et al (249 pts.) – 1.2%
C. Warfarin Prophylaxis after TKA c. Le Clerc et al (1,142 pts.) – 0%
a. 6 randomized trials C. Recommend – Prophylaxis should be continued beyond
b. In general, LMWHs are significantly more effective in hospital discharge. Minimum of 7 to 10 days of prophy-
reducing asymtomatic DVT rate laxis with LMWH and at least 2 weeks of Warfarin pro-
i. Fitzgerald et al - decreased proximal clot formation phylaxis. Symptomatic VTE events occur after hospital
(enoxaparin) discharge in 40-80% of patients. Further study of symp-
c. No differences in symptomatic PE or DVT rate tomatic DVT with extended duration of prophylaxis is
d. Bleeding complications more frequent with LMWH necessary in order to determine the duration of prophy-
i. Increase in transfusion requirement laxis that is really necessary.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
37
SYM 07:Layout 1 1/12/07 11:39 AM Page 38

VI. Screening VIII. Recommendation – DVT prophylaxis after THA

A. At this time screening can not be recommended LMWH
B. Recent studies not supportive of screening with ultra- Warfarin
sound Fondaparinux
1. Garino et al (JBJS, 1998)– Technician dependent Mechanical Devices-need further study
2. Robinson et al (1997) – US not justified
IX. Recommendation – DVT Prophylaxis After TKA
VII. Special Circumstances LMWH
A. Prior DVT or PE Warfarin
1. Pre-operative duplex scan Mechanical Devices
SYMPOSIA AR HIP

2. DVT prophylaxis-6 weeks Fondaparinux

B. Chronic Warfarin Usage
X. The Future of Prophylaxis
1. Stop Warfarin 5 days prior to operation
The future Gold-Standard—an oral agent that is safe and
2. Can use LMWH to protect patient, last dose 12 hours
effective but that does not require monitoring.
prior to surgery
3. Can use both drugs post-operatively depending on
DVT risk

REFERENCES 5. Hull R, Raskob G, Pineo G, Rosenbloom D, Evans W, Mallory T, Anquist K,

1. Colwell CW, Collis DK, Paulson R, McCutchen JW, Bigler GT, Lutz S, Hardwick Smith F, Hughes G, Green D, Elliot CB, Panju A, Brant R: A comparison of sub-
ME: Comparison of enoxaparin and warfarin for the prevention of venous cutaneous low-molecular weight heparin with warfarin sodium for prophylaxis
thromboembolic disease after total hip arthroplasty. J Bone Joint Surg Am against deep-vein thrombosis after hip or knee implantation. N Engl J Med
1999;81:932-940. 1993;329:1370-1376.

2. Gerts WH, Jay RM, Code KI, Chen E, Szalai JP, Saibil EA, Hamilton PA: A com- 6. Lieberman JR, Wollaeger J, Dore F. et al. The efficacy of prophylaxis with low-
parison of low-dose heparin with low-molecular-weight heparin as prophylaxis dose warfarin for prevention of pulmonary embolism following total hip arthro-
against venous thromboembolism after major trauma. N Engl J Med plasty. J Bone Joint Surg Am 1997:79:319-325.
1996;335:701-707. 7. Robinson Ks, Anderson DR, Gross M, et al. Ultrasonographic screening before
3. Horlocker TT, Wedel DJ: Neuraxial block and low-molecular-weight heparin: bal- hospital discharge for deep venous thrombosis after arthroplasty: the Post-
ancing perioperative analgesia and thromboprophylaxis. Reg Anesth Pain Med Arthroplasty Screening Study: a randomized, controlled trial. Ann Intern Med
1998;23:164-177. 1997;127:439-445.

4. Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, Holmzvist,

Mant M, Dear R, Bavlis B, Mah A, Bran R: Low molecular weight heparin pro-
phylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthro-
plasty patients: a double blind, randomized comparison. Arch Intern Med
2000;160:2199-2207.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
38 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 39

DEEP VEIN THROMBOSIS—LOW MOLECULAR WEIGHT

HEPARIN (LMWH) AND NEWER AGENTS
Clifford W. Colwell Jr, MD

Ideal prophylaxis would be: Combining two studies with over 1,600 THA patients, the over-
• Effective (clinically proven) all DVT rate for fondaparinux was 5% with a proximal DVT rate

SYMPOSIA AR HIP
• Low risk of side effects of approximately 2%.10,11 No major bleeding was reported,
• Practical for use but overall bleeding was 3%. As with all interventions, the ben-
• Easy to administer and monitor efit has to be considered against the risk in use of any anticoag-
• Cost effective ulants.
Unfortunately, no current method of prophylaxis meets all of LMWH prophylaxis can be safely used with single-injection or
these standards. In the American College of Chest Physicians continuous catheter neuraxial anesthesia techniques.7 The rec-
(ACCP) guidelines, both low molecular weight heparin ommendations can be found on the American Society of
(LMWH) and fondaparinux, a synthetic factor Xa inhibitor, Regional Anesthesia (ASRA) web site
received the highest rating (A-1) for prophylaxis for THA.5
(http://www.asra.com/publications/consensus-statements-
LMWH are fragments of unfractionated heparin produced by 2.html) and include the following:
either chemical or enzymatic depolymerization. LMWH have a
• Twice daily dosing:
mean molecular weight from 4,000 to 6,000 daltons compared
— 1st dose administered no earlier than 24 hours postoper-
with unfractionated heparin (UFH), which has a mean molecu-
atively and only in the presence of adequate surgical
lar weight of 15,000 daltons. Absence of protein binding gives
hemostasis.
LMWH excellent bioavailability and a predictable response
— Indwelling catheters should be removed prior to initia-
when administered in fixed doses.6 LMWH also have a two- to
tion of LMWH thromboprophylaxis. Continuous
four-fold longer half-life than UFH, allowing for dosing only
indwelling epidural catheter can be left in overnight and
once or twice daily.6 Clearance of LMWH is primarily renal,
the 1st dose of LMWH administered 2 hours after
which may increase their half-life in patients with renal failure.6
catheter removal.
Currently, two LMWH are approved for use in THA in the
• Single daily dosing:
United States, enoxaparin and dalteparin. Although results of
— 1st dose administered 6 – 8 hours after surgery.
studies with LMWH were similar, dosing is different for each
— Indwelling catheters may be safely maintained. The
LMWH. Low molecular weight heparins have been studied
catheter should be removed a minimum of 10 – 12
extensively in total hip arthroplasty (THA) and provide both
hours after the last dose of LMWH and the next dose
highly effective and safe DVT prophylaxis. The prevalence of
should occur a minimum of 2 hours after the catheter is
DVT with LMWH prophylaxis was 16% in a combination of
removed.
THA studies involving over 6,000 patients, with a relative rate
• Fondaparinux
reduction of 70% compared to placebo. In these same studies,
— Until further clinical evidence is accrued, fondaparinux
the prevalence of proximal DVT was 6%.4 Comparing placebo,
should be utilized in the same manner it was in clinical
UFH, and LMWH, significantly more DVT, both total (43%)
trials (single needle pass, atraumatic needle placement,
and proximal (22%), occurred in the placebo group (43%) than
avoidance of indwelling neuraxial catheters).
either of the other groups (LMWH 14% and 4%; UFH 16% and
5%, respectively).1 Major bleeding occurred in both the place- The length of prophylaxis for THA patients remains controver-
bo and LMWH group at 4% and in the UFH group at 6%. sial. Two studies with LMWH that continued prophylaxis to 21
Another study demonstrated a significant decrease in DVT to 35 days indicated that a number of DVT could be avoided by
whether the LMWH was give preoperatively (11%) or postoper- prolonging therapy.2,8 In both studies, patients received pro-
atively (13%) compared with warfarin (24%). However, major phylaxis while hospitalized, then were randomized to either
bleeding rates were significantly higher (9%) when the LMWH LMWH treatment or placebo. In the 21-day treatment study, 8%
was given preoperatively compared with warfarin (5%).9 of patients given LMWH prophylaxis compared with 23% of
patients receiving placebo had DVT by venography.2 The THA
LMWH is given by subcutaneous injection and can be started 12
patients receiving prophylaxis for 35 days had 5% DVT in the
hours before surgery, or 12 to 24 hours after surgery, or 4 to 6
LMWH group and 10% DVT in the placebo group.8
hours after surgery at half the usual dose. Major bleeding rate
reported for low molecular weight heparin is about 5% com- New pharmacological substances being tested may impact the
pared with about 4% in placebo trials.5 According to the way we provide prophylaxis to THA patients. Currently trials are
GLORY data, surgeons in the USA report using LMWH prophy- being performed on two new oral anticoagulant agents and pos-
laxis on 43% of THA cases compared with a reported 90% in sibly others that we are unaware of. If the results of the trials of
other countries.3 these compounds are positive and receive FDA approval, they
may in some cases replace the current injectable anticoagulants.
Another choice available is a synthetic pentasaccharide, fonda-
parinux, which also received an A1 rating in the ACCP recom-
The bottom line:
mendations.5 Fondaparinux is manufactured by total chemical
• LMWH provides a 70% RRR for any DVT and a 78% RRR
synthesis. Given in a single 2.5 mg dose daily, fondaparinux has
for proximal DVT compared with placebo.
100% bioavailability and a half-life of 17 hours. The drug binds
• Fondaparinux provides a 45% RRR for any DVT compared
to antithrombin, provides a predictable dose response, and is
with enoxaparin and a 78% RRR compared with placebo.
excreted through the kidneys.12

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
39
SYM 07:Layout 1 1/12/07 11:39 AM Page 40

REFERENCES 8. Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, Holmqvist
1. Colwell CW, Jr., Spiro TE. Efficacy and safety of enoxaparin to prevent deep vein A, Mant M, Dear R, Baylis B, Mah A, Brant R. Low-molecular-weight heparin pro-
thrombosis after hip arthroplasty. Clin Orthop. 1995;215-222. phylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-
hospital placebo in hip arthroplasty patients: a double-blind, randomized com-
2. Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA, Jr., parison. North American Fragmin Trial Investigators. Arch Intern Med.
Landon GC, Jove M. Prolonged enoxaparin therapy to prevent venous throm- 2000;160:2208-2215.
boembolism after primary hip or knee replacement. Enoxaparin Clinical Trial
Group. J Bone Joint Surg Am. 2001;83-A:336-345. 9. Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, Holmqvist
A, Mant M, Dear R, Baylis B, Mah A, Brant R. Low-molecular-weight heparin pro-
3. Friedman, Gallus, Cushner, FitzGerald G, Anderson, Jr. Compliance with ACCP phylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthro-
Guidelines for Prevention of Venous Thromboembolism: Multinational findings plasty patients: a double-blind, randomized comparison. The North American
from the Global Orthopaedic Registry (GLORY). ASH . 8-18-2003. Fragmin Trial Investigators. Arch Intern Med. 2000;160:2199-2207.
SYMPOSIA AR HIP

4. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA, Jr., Wheeler 10. Lassen MR, Bauer KA, Eriksson BI, Turpie AG. Postoperative fondaparinux versus
HB. Prevention of venous thromboembolism. Chest. 2001;119:132S-175S. preoperative enoxaparin for prevention of venous thromboembolism in elective
5. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. hip-replacement surgery: a randomised double-blind comparison. Lancet.
Prevention of venous thromboembolism: the Seventh ACCP Conference on 2002;359:1715-1720.
Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338S-400S. 11. Turpie AG, Bauer KA, Eriksson BI, Lassen MR. Postoperative fondaparinux versus
6. Hirsh J, Warkentin TE, Raschke R, Granger C, Ohman EM, Dalen JE. Heparin and postoperative enoxaparin for prevention of venous thromboembolism after elec-
low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing tive hip-replacement surgery: a randomised double-blind trial. Lancet.
considerations, monitoring, efficacy, and safety. Chest. 1998;114:489S-510S. 2002;359:1721-1726.
7. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, Mulroy 12. Turpie AG, Eriksson BI, Bauer KA, Lassen MR. Fondaparinux. J Am Acad Orthop
MF, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS. Regional anesthesia in the Surg. 2004;12:371-375.
anticoagulated patient: defining the risks (the second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med.
2003;28:172-197.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
40 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 41

DISLOCATION AFTER TOTAL HIP

ARTHROPLASTY: WORLD PERSPECTIVES (U)

SYMPOSIA AR HIP
Moderator: Miguel E. Cabanela, MD, Rochester, MN (a, c, e - Stryker)
Dislocation after total hip arthroplasty is a disturbing problem for the patient and the
orthopaedic surgeon. Its frequency is higher than reported and recurrence of the condition
after corrective surgical treatment remains relatively high. Program faculty will review data
on epidemiology and etiology of the problem, results of surgical and non-surgical
management, and discuss some effective forms of management not used in the North
America.

I. Incidence of THA dislocation

Miguel E. Cabanela, MD, Rochester, MN (a, c, e - Stryker)

II. Etiology of THA dislocation

Robert B. Bourne, MD, London, ON Canada
(a, e - Smith & Nephew, a - DePuy, Zimmer)

III. Management of THS dislocation in Germany: Large heads

Carsten Perka, MD, Berlin, Germany (a, b - Zimmer, Endoplus, b - DePuy)

IV. Constrained liners: Pros and Cons

William N. Capello, MD, Indianapolis, IN (e - Stryker)

V. Dual-Mobility sockets
Jean-Noel A. Argenson, MD, Marseille, France (n)

VI. Experience with THA dislocation in the Wrightington Hospital, UK

M.L. Porter, MD, Lancs, United Kingdom (n)

VII. Management of THA dislocation Down-Under

Rocco P. Pitto, MD, Auckland, New Zealand (n)

VII. THA dislocation in Sweden: Experience with EHDP augments

Johan N. Karrholm, MD, Goteborg, Sweden (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
41
SYM 07:Layout 1 1/12/07 11:39 AM Page 42

EPIDEMIOLOGY OF INSTABILITY AFTER

TOTAL HIP ARTHROPLASTY
M.E.Cabanela, M.D.

I. Introduction 3. Diagnosis: Certain groups of patients are at increased

A. Prevalence 0.3%-10% after primary THA in different dislocation risk: revision THA, patients with neuro-
SYMPOSIA AR HIP

studies muscular disease, patients treated with THA for

B. Most studies that report dislocation rates are short-term femoral neck fracture. Patients with cognitive dys-
studies. Dislocations can occur for the lifetime of the function appear to have a higher dislocation risk.
THA, therefore the cumulative risk of dislocation over B. Surgical factors
time is higher. 1. Exposure
a. anterolateral and transtrochanteric approaches have
II. Prevalence as a function of time
demonstrated lower dislocation risks than posterior
A. The risk of dislocation is highest the first year after THA
approaches
B. Late dislocations occur at low but steady state rate there-
b. in the last five years several studies have demon-
after.
strated a lower prevalence of early dislocation
(<1%) after posterior approach when a formal pos-
terior capsular repair is performed.
2. Femoral head size
a. Larger femoral head sizes are associated with a
lower rate of hip dislocation. A recent study
demonstrated the risk of dislocation for 32 mm
heads <28 mm heads <22 mm heads.

Berry DJ, von Knoch M, Schleck CD, Harmsen WS: The cumulative long-term
risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg
86A(1):9-14, 2004.

III. Factors that influence rate of dislocation

A. Demographic factors Berry DJ, von Knoch M, Schleck CD, Harmsen WS: Effect of femoral head diam-
1. Gender: females have a higher rate of dislocation eter and operative approach on risk of dislocation after primary total hip arthro-
than males by 2:1 or 3:1 ratios plasty. J Bone Joint Surg 87A:2456-2463, 2005.
2. Age: Older patients may have a slightly higher risk of
dislocation than younger patients, but the association
is not strong

REFERENCES 4. von Knoch M, Berry DJ, Harmsen MS, Morrey BF: Late dislocation after total hip
1. Sanchez-Sotelo J, Berry DJ: Epidemiology of instability after total hip replace- arthroplasty. J Bone Joint Surg 84A(11):1949-1953, 2002.
ment. Orthop Clinics NA 32(4):543-552, 2001. 5. Berry DJ, von Knoch M, Schleck CD, Harmsen WS: The cumulative long-term
2. Pellicci PM, Bostrom M, Poss R: Posterior approach to total hip replacement risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg
using enhanced posterior soft tissue repair. Clin Orthop 355:224, 1998. 86A(1):9-14, 2004.

3. Berry DJ, von Knoch M, Schleck CD, Harmsen WS: Effect of femoral head diam-
eter and operative approach on risk of dislocation after primary total hip arthro-
plasty. J Bone Joint Surg 87A:2456-2463, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
42 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 43

ETIOLOGY OF TOTAL HIP ARTHROPLASTY DISLOCATION

Robert B. Bourne

Dislocation after total hip arthroplasty is a devastating compli- Surgical Factors:

cation that leaves the patient with a lack of confidence in their While historical dislocation rates after primary THA cluster
hip, the surgeon with a tarnished reputation and health care around 2 percent to 5 percent, rates two to three times higher
payers with a financial liability. Most dislocations occur within have been noted following revision THA. The posterior surgical

SYMPOSIA AR HIP
the first few months of surgery, but dislocations can also occur approach has also been associated with the highest dislocation
late. rates and if this approach is used then posterior repair has been
demonstrated to be efficacious. Surgeon experience has also
Repeat dislocation occurs in up to 25 percent of patients after
been found to be an important risk factor, with low volume sur-
closed reduction with revision surgery usually recommended
geons having significantly higher THA dislocation rates, most
after three dislocations. Unfortunately, revision THA for recur-
likely due to component malpositioning outside Lewinnek’s
rent dislocation is successful in only 67 percent of patients. The
safe zone (15º ± 10º of anteversion and 40º ± 10º abduction),
best treatment for THA dislocation is prevention and this
failure to soft tissue balance the hip in terms of both leg length
requires an understanding of the patient, surgical and implant
and offset restoration and avoidance of implant, soft tissue and
factors implicated in the etiology of THA instability and strate-
bone impingement.
gies to minimize the risk of hip instability.
Implant Factors:
Patient Factors:
Implant impingement can serve as a fulcrum which allows the
Female patients have twice the risk for dislocation related to
femoral head to be levered out of the socket. Smaller femoral
more compliant soft tissues and greater hip range of motion.
head size, decreased head-to-neck ratio, the use of skirted
Older age has also been a risk factor for dislocation with demen-
femoral heads, bulky femoral neck designs, the use of lipped
tia, lack of compliance, muscle weakness and poor balance
socket designs, and polyethylene wear are implant factors that
being implicated. In addition, patients with neuromuscular dis-
can contribute to post-operative dislocation.
orders are also known to be at risk for THA dislocation due to
spasticity, contractures, poor muscle control, poor balance and
Summary:
falls. Poor patient compliance related to substance abuse (ie.
Understanding the etiology of total hip arthroplasty can aid in
alcohol), poor cognition, (ie. dementia) and comorbidities are
preventing this complication and lead to better patient out-
also important risk factors for THA dislocation.
comes.

REFERENCES 5. Katz, Jeffrey N., Losina, E., Barrett, J., Phillips, Charlotte B., Mahomed, Nizar N.,
1. Berry, D.J. Dislocation In Revision Total Hip Arthroplasty, Ed. M.E. Steinberg and Lew, Robert A., Guadagnoli, Edward, Harris, William, Poss, Robert, and Baron,
J.P. Garino, Lippincott Williams and Wilkins, Philadelphia, 463-481, 1999. John A. Association Between Hospital and Surgeon Procedure Volume and
Outcomes of Total Hip Replacement in the United States Medicare Population.
2. Chandler, R.W., Dorr, L.D., and Perry, J. The Functional cost of Dislocation J. Bone Joint Surg. Am., 83: 1622 - 1629, 2001.
Following Total Hip Arthroplasty. Clin Orthop, 168: 168-172, 1982.
6. Krushell, R.J., Burke, D.W., and Harris, W.H. Elevated-rim Acetabular
3. Charles, M., Bourne, R.B., Dowey, J.R., Morrey, B.F., and Rorabeck, C.Y. Soft Components: Effect on Range of Motion and Stability in Total Hip Arthroplasty.
Tissue Balancing of the Hip - The Role of Femoral Offset Restoration. J Bone J. Arthroplasty, 65: 53-58, 1991.
Joint Surg, 86A: 1078-1089, 2004.
7. Lewinnek, G.E., Lewis, J.L., Tan, R., Compere, C.L.. and Zimmerman, J.R.
4. Cobb, T.K., Morrey, B.F., and Ilstrup, D.M. The Elevated-rim Acetabular Liner in Dislocations After Total Hip Replacement Arthroplasties. J. Bone Joint Surg, 60A:
Total Hip Arthroplasty: Relationship to Postoperative Dislocation. J Bone Joint 217-220, 1978.
Surg, 78A: 80-86, 1996.
8. Morrey, B.F., Instability After total Hip Arthroplasty. Orthop Clin North Am,
N23: 237-242, 1992.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
43
SYM 07:Layout 1 1/12/07 11:39 AM Page 44

THE GERMAN EXPERIENCE WITH LARGE DIAMETER HEADS

Carsten Perka

Postoperative dislocation is the most common complication in These are:

revision hip surgery. Several authors cite a prevalence of dislo- In primary THA
cation in primary THR ranging between 0.5% - 4% and up to • previous surgery (e.g. posttraumtic arthritis)
21% in revisions. Factors related to higher dislocation rates are • age > 80 years
SYMPOSIA AR HIP

surgical approach, previous surgery on the hip, age, female gen- • diagnosis (avascular necrosis)
der, cognitive function and underlying diagnosis.1 The majori- • limited cognitive function of the patient
ty of dislocations occur within the first tree months after surgery • neuromuscular disorder
and is at highest immediately after the operation. • large range of motion before surgery (flexion > 120°)
• patient suspicious for non-compliance
Larger diameter heads are an option to prevent dislocation in
In addition in revision THR
total hip replacement. The jump distance (the distance the head
• posterior approach
must move to disengage from the socket) is higher with a larg-
• revision for recurring dislocation
er femoral head, which is less probable to dislocate. Heads with
• abductor injury or damage
a diameter of more than 32 mm are defined larger diameter
• missing greater or lesser trochanter
heads. In the past larger heads had produced more wear when
• malposition of stable components (rare cases)
articulating with conventional UHMWPE.2 With the evolution
• general laxicity.
of alternative bearing materials, such as metal-on-metal articu-
lation or metal-on-highly cross-linked PE, the use of larger head We have retrospectively reviewed all THA procedures with one
sizes may provide increased stability without compromising the of the above mentioned risk factors, were a 36 mm metal head
wear properties. 3 was implated versus a highly cross-linked PE insert (Durasul or
Longivity, Zimmer Inc, Warsaw, IN). 86 cases were included and
Beside the tribology there are concerns using large diameter
clinically followed up 3 months after surgery. Two hips (two
heads. With an increase of head size, PE thickness decreases,
patients) dislocated, both having had a minimum of four pre-
which changes the mechanical properties and may negatively
vious operations and lacking of pelvitrochanteric muscles.
influence the fracture resistance and may lead to fatigue cracks.4
By using a metal-on-metal bearing with a large diameter head In our experience the use of large diameter heads can reduce the
the wear can be reduced in comparison to small femoral head risk of postoperative dislocation of patients at risk. As a result of
diameters through an early achievement of a thick fluid-film our encouraging results we continue to use large diameter
interface. But potential risks through elevated serum concentra- femoral heads with an metal-on-highly cross-linked PE bearing.
tions and urine levels of metal ions produced during the life The most important issue regarding the use of large diameter
span of a metal-on-metal articulation must be taken into heads against polyethylene is the yet unknown long term behav-
account.5 Additionally hypersensitivity and lymphocytic iour of thin highly cross-linked polyethylene inserts.
perivascular infiltration seem to be a possible complication of
Thus we have to balance the potential long term shortcomings
metal-on metal bearings.6
against the risk of hip dislocation. From our standpoint the use
Summarizing only short term and some of them concerning of large femoral heads for patients having a relevant risk for hip
results are available with larger femoral heads. As consequence dislocation seems acceptable. But a general use can not be justi-
of this limited knowledge a careful selection of patients in fied up to now.
which large diameter heads should be used is necessary. In our
department large femoral heads are used for all patients with an
increased risk for postoperative dislocation.

REFERENCES 4. Greenwald AS, Bauer TW, Ries MD. New polys for old: contribution or caveat?
1. Smith TM, Berend KR, Lombardi AV Jr, Emerson RH Jr, Mallory TH. Metal-on- JBJS 83A (Suppl. 2) 2001;27-31
metal total hip arthroplasty with large heads may prevent early dislocation. Clin 5. Schmalzried TP. How I choose a bearing surface for my patients. J. Arthroplasty
Orthop Relat Res. 2005;441:137-42. 2004;19:50-53
2. Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing techniques and 6. Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann
femoral component loosening in young patients with hip arthroplasty. A 12-year CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip
radiographic review. J Bone Joint Surg Br. 1992;74:385-9. joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005
3. Crowninshield RD, Maloney WJ, Wentz DH, Humphrey SM, Blanchard CR. Jan;87(1):28-36.
Biomechanics of large femoral heads: what they do and don’t do. Clin Orthop
Relat Res. 2004;429:102-7.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
44 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 45

CONSTRAINED LINERS
William N. Capello, MD

Constrained acetabular components have been available to reduction and open reduction is almost always necessary. In
address hip instability for a number of years. Currently there are those settings where the constrained component is one with a
two types of constrained components; one where the femoral captured bipolar, thus two joints, there is always a concern of
head is captured within the polyethylene and some type of increased polyethylene wear. Although neither published study

SYMPOSIA AR HIP
retaining ring to reinforce the capture. The amount of motion suggests at least in the intermediate term that this is a problem.
allowable by this type of component is to a large extent related
The current indications for the use of constrained components
to head diameter though some have cutouts and other methods
include those patients whose instability is related to soft tissue
of improving range of motion. The second type of component
inadequacy such as abductor insufficiency either through surgi-
is one where a small bipolar component is pre-assembled with-
cal trauma or trochanteric non union or neurologic compro-
in the polyethylene liner and the femoral head of the femoral
mise. They are also indicated in patients who have undergone
component is then inserted into the bipolar thereby creating a
other procedures to address instability and those procedures
situation with two joints a metal plastic joint representing the
have been unsuccessful. An additional indication, are patients
femoral head and the inside of the bipolar joint and then a sec-
with neurologic problems such as Parkinson’s, senility, post
ond joint another metal plastic joint with the bipolar outer sur-
polio weakness. The contraindications include significant mal-
face articulating with the inner surface of the acetabular liner.
positioning of either femoral or acetabular component. Another
The advantage to this construct is that it allows for more motion
relative contraindication may be their implantation in very poor
because of the outer bearing being of a large diameter, that is the
bone. It is feared that the possible increased stresses at the bone
constrained bipolar. The literature would suggest that the failure
cement interface related to the use of these constrained compo-
rates associated with these components vary from as low as less
nents may place untenable forces on that interface causing loos-
than 5% to as high as 29%. These results are somewhat design
ening. Some surgeons suggest that if one is dealing with unsta-
dependent with two major articles looking at the constrained
ble situation in face of poor bone stock that the acetabular
bipolar type component shows lower overall failure rates than
comp be implanted with a non constrained component and if
can be found in the literature with the femoral head captured
the patient has subsequent instability then move to constrained
within the acetabular component.
component and by the time it is thought that the acetabular
The pros in support of using these components include their component would have achieved good bone ingrowth and be
ease of use. They fit into standard acetabular components either able to tolerate any additional stresses placed by the constrained
through a locking mechanism or they can be secured into exist- component. These components are not recommended for rou-
ing acetabular components with PMMA bone cement. Their tine use in primary total hips in pts without significant neuro-
intermediate term follow up would suggest that they are durable logic impairment or obvious muscle imbalance.
and have an acceptable failure rate. They address a variety of
It is this author’s opinion that these components continue to
problems associated with instability. The potential problems
serve a valuable function in our attempt to address recurrent
with them are they can place significant force on the bone pros-
instability following hip arthroplasty.
thetic interface in the acetabulum and a loosening might occur
there. If they disassemble there is little likelihood of a closed

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
45
SYM 07:Layout 1 1/12/07 11:39 AM Page 46

THE USE OF DUAL-MOBILITY SOCKETS IN

TOTAL HIP ARTHROPLASTY
Jean-Noel A.Argenson, MD

Instability following total hip arthroplasty (THA) is still a remain- This distinction is important to differentiate such design from
ing problem and the treatment of recurrent dislocation may rep- the so-called dual-mobility socket introduced in France by
SYMPOSIA AR HIP

resent a challenge for the orthopaedic surgeon. The frequency of Bousquet . The original design included a cementless acetabular
dislocation following THA averages 3 % with incidence as high socket coated with aluminium ceramic and fixed with two pegs
as 20 % in case of multi-operated hips or component revision.1 (one directed to the pubis and the other to the ischium) and
one iliac screw. The constraint polyethylene liner captures a 22.2
When the reason of dislocation is clearly identified the surgical
mm cobalt chrome head, and the liner is free and mobile in the
treatment may be successful for preventing or treating recurrent
metallic shell. Therefore the friction occurs mainly at the level of
dislocation. This includes the correction of a malpositioned
the 22.2 mm diameter and dislocation can only occur at the
component, the removal of bony and soft tissue impingment, or
biggest diameter level requiring a much higher decoaptation
the modification of the greater trochanter position.2,3 Increasing
force of the prosthesis.10 The concept has then be extended to
the size of the femoral head using large metal balls has been pro-
other designs including hydroxyapatite coated cups and 28 mm
posed in order to reduce the possibility of dislocation while pre-
diameter femoral heads. In a large multicentric study reported
serving or increasing range of motion. There is still, with this
recently by Leclerq et al., 238 dual-mobility sockets used for
technique, a 13.7 % persistent failure risk of further dislocation.4
treatment of recurrent instability were evaluated at a 3 to 20
When the causes are multifactorial or in case of predisposing year-followup. This series included 7 different devices preserving
factors such as muscular weakness or neurological disorders the dual-mobility concept (Bousquet Al, Bousquet Novae,
specific implant designing solutions have been proposed. Biomet, EOL, Evora, Gyros, Saturne). The average number of dis-
location before using the dual-mobility socket was 4 (range, 1 to
One of them, popular in the United States, is described as a con-
13). At the time of last followup the average Postel Merle
strained liner featuring a locking mechanism to capture the femoral
d’Aubigne score was 15. Four hips were revised for a mechanical
head and thereby prevent dislocation. With a such constrained
reason at the level of the acetabulum including two migrations
liner design Della Valle et al. reported a 16% failure for further dis-
and two intra-prosthetic dislocations (at 1 and 14 years), a spe-
location using the Duraloc device in 55 cases, all failures occurring
cific complication of such designs. The overall failure rate for
via the locking ring with dislocation of the femoral head.5 With the
recurrent dislocation was 3.3 %.11 Philippot et al. evaluating a
S-ROM device, which uses extra polyethylene at the rim of the liner
retrospective series of 106 dual-mobility sockets implanted
to capture the femoral head, Berend et al. reported a 71 % success
mainly for primary osteoarthritis and using the Novae device
for preventing further dislocation but encouraged a cautious use of
reported no episodes of instability and a 94.6 % survival of the
such device regarding the 42 % long term failure rate reported in
socket at ten years. Two cases of intra-prosthetic dislocation due
their large series of 755 cases.6 The Trident device has been associ-
to polyethylene wear were noted , and this loss of the remaining
ated with lower rates of recurrent instability averaging 7% in the 56
rim was presented as the main limitation of the method.12
cases studied by Goetz et al. after a 10-year average followup.7
Callaghan et al. found a 7 % recurrent dislocation rate when this In conclusion the dual-mobility concept features from inside-
device was cemented into a fixed cementless acetabular shell.8 Khan out a first mobility site between the femoral head and the con-
et al. had the similar positive experience for preventing recurrent straint liner, and a second one between the polyethylene liner
dislocation but with an overall 11.8% rate of aseptic loosening at 3 and the inner metallic part of the shell. The concept appears
years followup.9 The particularity of this design known as a tripolar effective for treating recurrent instability following THA with an
cup, consists of a polyethylene concave liner capturing the femoral acceptable survival rate for component fixation at ten years. The
head and articulating through its polished Co-Cr shell with anoth- loss of constraint occurring with time and due to polyethylene
er polyethylene liner either inserted in a standard cup or cemented wear remains a specific issue of the design requiring revision for
in any acetabular shell. intra-prosthetic dislocation.

REFERENCES 7. Goetz DD, Bremmer BR, Callaghan JJ, Capello WN, Johnston RC. Salvage of a
1. Morrey BF. Results of reoperation for hip dislocation: the big picture. recurrently dislocating total hip prosthesis with use of a constrained acetabular
Clin Orthop 2004;429:94-101. component. J Bone Joint Surg 2004;86-A:2419-2423.

2. Daly PJ, Morrey BF. Operative correction of an unstable total hip arthroplasty. J 8. Callaghan JJ, O’Rourke MR, Goetz DD, Lewallen DG, Johnston RC, Capello
Bone Joint Surg 1992;74-A:1334-1343. WN. Use of a constrained tripolar acetabular liner to treat intraoperative instabil-
ity and postoperative dislocation after total hip arthroplasty. Clin Orthop
3. Kaplan SJ, Thomas WH, Poss R. Trochanteric advancement for recurrent disloca- 2004;429:117-123.
tion after total hip arthroplasty. J Arthroplasty 1987;2:119-124.
9. Khan RJ, Fick D, Alakeson R, Haebich S, De Cruz M, Nivbrant B, Wood D. A
4. Amstutz HC, Le Duff MJ, Beaule PE. Prevention and treatment of dislocation constrained acetabular component for recurrent dislocation. J Bone Joint Surg
after total hip replacement using large diameter balls. Clin Orthop 2006;88-B:870-876.
2004;429:108-116.
10. Leclerq S, El Blidi SE, Aubriot JH. Bousquet’s prosthesis for recurrent total hip
5. Della Valle CJ, Chang D, Sporer S, Berger RA, Rosenberg AG, Paprosky WG. High prosthesis dislocation. Rev Chir Orthop 1995;81:389-394.
failure rate of a constained acetabular liner in revision total hip arthroplasty. J
Arthroplasty 2005;20(Supp.3):103-107. 11. Leclerq S, Richter D, Aubriot JH, Bonnan J, Burdin P, Derhi G, Descamps L, Epinette JA,
Guyen O, Lecuire F, Mertl P, Puch JM, Lemarechal P, Combes J, Bejui J. Treatment of
6. Berend KR, Lombardi AV, Mallory TH, Adams JB, Russell JH, Groseth KL. The recurrent dislocation in total hip arthroplasty using dual-mobility sockets. Presented at
long-term outcome of 755 consecutive constrained acetabular components in the annual meeting of the French Hip and Knee Society, Paris, November 2006.
total hip arthroplasty. J Arthroplasty 2005;20(Supp.3):93-102.
12. Philippot R, Adam P, Farizon F, Fessy MH, Bousquet G. Survival of dual-mobility
sockets: ten-year follow-up. Rev Chir Orthop 2006;92:326-331.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
46 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 47

EXPERIENCE WITH THA DISLOCATION IN

THE WRIGHTINGTON HOSPITAL
Mr Martyn Porter

This paper will review the Wrightington experience of disloca- The incidence of revision for dislocation 0.11%
tions following total hip arthroplasty with particular reference Nature of revision surgery

SYMPOSIA AR HIP
to management and outcomes. General philosophy, exploration, assessment and if neces-
sary component revision
Wrightington Perspective Three main causes of dislocation identified
The Centre for Hip Surgery at Wrightington Hospital, UK pro- Loss of abductor mechanism
vides specific focus with the Charnley low frictional torque Shortening of the limb
arthroplasty. The design attributes which make this prosthesis Mal-orientation of components
stand out from other designs is the relatively small diameter Outcome following revision
(22.225mm) femoral head and the use of all polyethylene 16 of 21 patients remained stable (approximately 75%)
cemented socket. Of remaining 5 patients one patient single dislocation
which stabilised
Incidence 4 remaining patients further dislocations but no further
• Nemann (1994) – incidence 0.4% revision
• Berry (2004) – incidence depends upon follow up Augmentation devices
1% at one month First described by Olerud (1985)
1.9% at one year Technique of screwing sector of HDP socket to original
7% at 25 years HDP socket. Also used by Wroblewski at Wrightington
Overall dislocation rate 4.8% Posterior lip augmentation device “PLAD”
• Phillips (2003) 58,521 THAs , incidence 3.39% within six Commercially available polyethylene with metal/polyethyl-
months of primary surgery ene augment. Can be positioned equatorially around the
Revision total hip 14.4% rim with screws. Converts conventional socket into
Captive socket.
Wrightington Data
Reported by Charlwood (2001)
Study No 1. Cupic and Charnley 1974 and Etienne et al 22 patients, 100% success
1978.
Experience with Charnley LFA outside Wrightington
Three time cohorts
Study by Hedlundh et al (1997)
Time cohort 1: 1963-1965 409 THAs, dislocation rate 2%
Study of 3,685 THAs
Time cohort 2: 1966-1978 5,000 THAs, dislocation rate
121 dislocations – incidence of 3.3%
0.6%
822 revision hips, dislocation incidence 4.7%
Time cohort 3: 1972 1,200 THAs, dislocation rate 0.25%
Fate following manipulation of dislocations
Timing of Dislocations
35% of hips stable after first reduction
33 dislocations
31% stable after second reduction
30% immediate dislocation (within 3 days)
23% stable after third reduction
66% dislocated before 6 weeks
Risk factors of re-dislocation
75% dislocated before 6 months
Not influenced by age, diagnosis, primary or revision or
Factors associated with dislocation
time to first dislocation
Detachment of the greater trochanter
But influenced by male gender (risk ration 1.6)
Instability noted during the operation
Revision operation for hip instability
High placement of the socket
72 operations, 15 re-operations and 57 revisions
Shortening of the lower limb extremity
Of the 15 re-operations
Conversion from previous surgery
1 open reduction plus capsule repair
Treatment of dislocation
8 trochanteric reattachments
78% treated by closed methods
1 removal of osteophytes
Postoperative treatment bed rest with traction for 3 weeks!
3 adductor tenotomies
(Note 1974 study.)
2 cup augmentation (Olerud)
80% of hips stable after reduction.
Success rate (2 years post op) approximately 30%
Sex, age, original diagnosis did not influence incidence of
Of the 57 revisions
dislocation.
28 cup exchange
Study No 2. Fraser and Wroblewski 1981 13 stem exchange
14,672 THAs performed between November 1962 to June 9 exchange of cup and socket
1979. 7 pseudarthrosis
Dislocation rate 92 patients – 0.63% Success rate 63% for whole group
16 patients dislocated more than once and required revi- 100% when both components were exchanged
sion operations.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
47
SYM 07:Layout 1 1/12/07 11:39 AM Page 48

Key Facts 3rd dislocation: May reduce third time but low threshold to
• Incidence of dislocation varies by an order of magnitude consider use of posterior lip augmentation device +/- use of
(0.4 to 4%) anti-dislocation brace.
• Dislocation following Charnley hip replacement (small
4th dislocation: Consider full revision. Tendency to revise both
diameter head) can be low (less than 1%)
components, to increase head size and use a semi-captive cup,
• Fate of dislocations following reduction varies, success rate
PLAD or Captive cup depending on intra-operative findings.
between 30 to 75% following first reduction
• Only about 20% of hips that dislocate will require further Final resort: Consider two stage revision, the first stage to pseu-
surgery. do, allow fibrosis to occur and consider secondary implantation
SYMPOSIA AR HIP

or leave permanently as a pseudo.

Present Wrightington Protocol
1st dislocation: Reduce and EUA under image intensifier. There are always exceptions to any treatment protocols or guide-
Normally early rehab. Brace, “unreliable” or “vulnerable”. lines. At all times it is necessary to involve the patient (informed
Open reduction only if strictly necessary. consent). Consider individual requirements and requests from
patients and finally consider patient specific anatomy and kine-
2nd dislocation: Reduce and EUA under image intensifier.
matics.
Normally brace six weeks full compliance and then further six
weeks day time use only. Total 12 weeks.

REFERENCES 6. Charnley J, Cupic Z. Etiology and Incidence of dislocation in the Charnley Low-
1. Berry DJ, Scott Harmesen W, Cabenela M E, Morrey B. Twenty Five Year Friction Arthroplasty. Internal Publication No 46. Centre for Hip Surgery,
Survivorship of Two Thousand Consecutive Primary Charnley Total Hip Wrightington Hospital. Jan 1974.
Replacements. JBJS Vol 84a, No 2, Feb 2002. 171-177 7. Etienne A, Cupic Z, Charnley J. Post-Operative Dislocation after Charnley Low-
2. Berry DJ, Von Knoch M, Scheleck CD, Scott Harmesen W. The Cumulative Long Friction Arthroplasty. Clinical Orthopaedics and Related Research. 1978. No
Term Risk of Dislocation After Primary Charnley Total Hip Arthroplasty. JBJS, 132. 19-23
Vol 86A, No 1, Jan 2004. 8. Fraser GA, Wroblewski BM. Revision of the Charnley Low-Friction Arthroplasty
3. Charlwood P, Thompson NW, Brown JG, Nixon JR. The Belfast Posterior Lip for Recurrent or Irreducible Dislocation. JBJS, Vol 63B, No 4, 1981. 552-555.
Augmentation Device (Plad) in the Management of Recurrent Posterior 9. Hedlundh U, Sanzen L, Fredlin H. The Prognosis and Treatment of Dislocated
Dislocation Following Primary Total Hip Arthroplasty. British Hip Society Total Hip Arthroplasties with a 22mm Head. JBJS, Vol 79-B, No 3, May 1997.
Annual Meeting 2001, Cambridge. 375-377
4. Charnley J. Avoidance of Post-Operative dislocation in the Surgical Technique of 10. Joshi A, LeeCM, Markovik L, Viatis G, Murphy JC. Prognosis of dislocation after
Low-Friction Arthroplasty. Internal Publication No 36. Centre for Hip Surgery, total hip arthroplasty. J Arthroplasty. 1998;13:17-21.
Wrightington Hospital. Jan 1972. 11. Olerud S, Karlstrom G. Recurrent Dislocation After Total Hip Replacement:
5. Charnley J. The Long Term Results of Low-Friction Arthroplasty of the Hip. Treatment by Fixation of Additional Sector of the Acetabular. JBJS 1985, 67-B.
Internal Publication No 25. Centre for Hip Surgery, Wrightington Hospital. 402-405.
Presented to the British Orthopaedic Association, London Sept 1970. 12. Neumann L, Freund KG, Sorenson KH. Long-term results of Charnley total hip
replacement. Review of 92 patients at 15 to 20 years. Journal of Bone and Joint
Surgery Br. 1994;76:245-51

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
48 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 49

MANAGEMENT OF TOTAL HIP ARTHROPLASTY DISLOCATION

DOWN-UNDER
R.P. Pitto, S. Young, S. Graves

While total hip arthroplasty (THA) is an effective surgical pro- lized to increase joint stability. Dual-mobility sockets, a relative-
cedure for the management of hip fractures and degenerative ly new technology Down-Under, were used in a small number

SYMPOSIA AR HIP
joint disease, dislocation remains the second leading cause of of procedures. Subsequent revision rate for major partial, major
revision. With approximately 37,000 THA procedures per- total and minor revisions of known primary surgical procedures
formed every year in Australia and New Zealand, even low rates was 9.4%
of instability can cause substantial morbidity together with high
The effect of non-recurrent THA dislocation treated conserva-
social costs (1, 2).
tively with closed reduction on functional outcome was
The datasets of the Australian Orthopaedic Association National assessed in a sub-group of Australian patients (3). The study
Joint Replacement Registry and the New Zealand Orthopaedic showed no statistical difference between patients who do or do
Association National Joint Replacement Registry were analyzed not suffer a dislocation with regard to SF-12 and WOMAC out-
to determine the contemporary surgical management of recur- comes, but those who dislocate are significantly less satisfied
rent THA dislocation Down-Under. Even though there are sev- following THA in the medium term.
eral differences between the two countries in terms of health
The influence of THA dislocation requiring revision surgery on
care systems and some other social features, surgical training,
functional outcome was assessed in the dataset of the NZ reg-
overall orthopaedic surgeon culture and attitudes, availability of
istry. As expected, at the 6-month follow-up we found a marked-
implants and patient demographics are reasonably similar.
ly worse Oxford Hip Score when compared to matched cases
Therefore, we assumed that patient population and surgical
that did not had surgery for THA dislocation.
management in the two counties are homogeneous. Thus, we
elected to combine the two registry datasets for the purposes of
this study.
The true rate of dislocation after THA remains unknown, large-
A total of 165,000 procedures were included in the study (hemi- ly because the population at risk is difficult to monitor. This
arthroplasties, primary THA and revision THA). 25,237 revision arthroplasty registry study was designed to determine the con-
THA procedures were performed since inception of the temporary surgical management of recurrent THA dislocation in
Registries. Dislocation was the most frequent reason for revision Australia and New Zealand. A wide number of surgical tech-
following mechanical loosening. Thirteen percent (3,254 surgi- niques and implants have been used. It appears that surgical
cal procedures) of revisions were performed to manage recur- management to address this difficult problem does not marked-
rent dislocation of the implant *. To manage the problem of ly differ from current treatment strategies in Europe and North
recurrent dislocation, a new socket to improve implant orienta- America.
tion was used in a large number of procedures. Exchange of
*Figures available at the stage of submission of the present manu-
stem was performed in a limited number of surgical procedures.
script.
Constrained liners or full-polyethylene socket wedges were uti-

REFERENCES 3. Forsythe ME et al.: Functional outcomes following non-recurrent dislocation of

1. Annual Report Australian Orthopaedic Association National Joint Replacement primary THA. Proceedings of the Combined Scientific Meeting AOA-NZOA,
Registry, 2006 – www.aoa.org.au Canberra, Australia, 107, 2006

2. Annual Report New Zealand Orthopaedic Association National Joint

Replacement Registry, 2006 – www.nzoa.co.nz

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
49
SYM 07:Layout 1 1/12/07 11:39 AM Page 50

SOCKET WALL ADDITION DEVICE FOR

RECURRENT HIP DISLOCATION
Johan Kärrholm MD, PhD, Göran Garellick MD, PhD

Olerud and Karlström (7) were probably the first to describe a primary (59%) or posttraumatic (29) osteoarthritis. The average
device to increase the surface of the socket with the intention to follow-up was 5 years and 8 months 1 day - 22.5 years.
SYMPOSIA AR HIP

resist dislocation of a hip prosthesis. They cut out a sector of a

Results. The first operation was done in 1983. Until 1988 less
new Charnley cup with a saw and fixed it to the Charnley cup
then 10 procedures were done per year. From 1989 the incidence
in the patient with screws. Later manufactures of cemented cups
of these operations increased slowly up to about 70-80/year
developed dedicated devices such as the posterior lip augmen-
between 2003 and 2005. The overall crude rate of reoperation
tation device (PLAD, DePuy, Leeds, England) or the antiluxation
because of repeat dislocation was 12% with an annual variation
ring (ALR, Waldemar Link GmbH, Hamburg, Germany).
between 4 and 21%. The survival rate (Kaplan-Meier) using any
Insertion of any such cup augment has the advantage of being
reoperations because of dislocation as endpoint showed an early
comparatively easy. It is minimally invasive and is associated
rapid decrease during the first 5 years and levelling at 83.5%
with faster rehabilitation and less morbidity compared to revi-
(SEM=1.5%) after almost 11 years (175 remaining observations).
sion/exchange of the components.
In the literature there are 10 to 15 clinical reports (1-11, for
review see 3). Most of them have a maximum follow-up of 2-3
years. These studies included between 2 and 68 patients. In 8 of
these reports, including 10 cases or more, the incidence of redis-
location has varied between 0 and 24%.
So far the efficacy of this procedure is still uncertain because of
few reports with limited number of patients and comparatively
short follow-up. To improve our knowledge in this field we eval-
uated the incidence of reoperations after insertion of wall addi-
tion device in the Swedish Hip Prosthesis register. Our outcome
parameter was reoperations because of recurrent dislocation.
Close reduction was excluded because we suspect high number
of unrecorded cases.
Survival of reoperations done with a socket wall addition device. At
Patients and Methods. Between 1979 and 2005 slightly mote 11 years follow up (175 remaining observations 83.5%
than 30 000 reoperations were recorded in the Swedish Hip (SEM=1.5%) had not been subjected to any further surgical pro-
Prosthesis Register. Of those 3384 (11.3%) were done because cedure due to continuing dislocation. Note that the number of
of dislocation. In 1945 (60%) of the cases one or several of the closed reductions is not known.
components were exchanged. A socket wall addition device was
used in 979 cases (29%). In the majority of these (892 of 979, Discussion. In Sweden use of an augmentation device to treat
91%) the femoral head was also exchanged. In 87 the cup recurrent dislocation turned out to be the definite treatment for
and/or stem was also changed. The majority of these procedures the dislocation in almost 85% of the cases. In this analysis we
(503, 51%) were first time reoperations. Almost all cups were did not account for revision because of other reason nor did we
cemented (964 of 979, 98.5%). The median age in patients include cases with further dislocations treated with close reduc-
operated with a wall device was 77 years 35-99, which was tion. At present questionnaires are sent out to all surviving
about three years older than those operated with other proce- patients concerning these issues including life quality (EQ-5D).
dures due to dislocation (p <0.0005). 65 % were female. The Further analyses of the database will be done to reveal the revi-
majority of the patients had primarily been operated because of sion rate because of other reasons than dislocations.

REFERENCES 6. Madan S, Sekhar S, Fiddian NJ. Wroblewski wedge augmentation for recurrent
1. Bradbury N, Milligan GF. Acetabular augmentation for dislocation of the pros- posterior dislocation of the Charnley total hip replacement. Ann R Coll Surg
thetic hip. A 3 (1-6)-year follow-up of 16 patients. Acta Orthop Scand. 1994 Engl. 2002 Nov;84(6):399-403.
Aug;65(4):424-6. 7. Mogensen B, Arnason H, Jonsson GT. Socket wall addition for dislocating total
2. Charlwood AP, Thompson NW, Thompson NS, Beverland DE, Nixon JR. hip. Report of two cases. Acta Orthop Scand. 1986 Aug;57(4):373-4.
Recurrent hip arthroplasty dislocation: good outcome after cup augmentation in 8. Nicholl JE, Koka SR, Bintcliffe IW, Addison AK. Acetabular augmentation for the
20 patients followed for 2 years. Acta Orthop Scand. 2002 Oct;73(5):502-5. treatment of unstable total hip arthroplasties. Ann R Coll Surg Engl. 1999
3. Enocson AG, Minde J, Svensson O. Socket wall addition device in the treatment Mar;81(2):127-32.
of recurrent hip prosthesis dislocation: good outcome in 12 patients followed for 9. Olerud S, Karlstrom G. Recurrent dislocation after total hip replacement.
4.5 (1-9) years. Acta Orthop. 2006 Feb;77(1):87-91. Treatment by fixing an additional sector to the acetabular component. J Bone
4. Gholve PA, Lovell ME, Naqui SZ. Minimal surgical approach for recurrent hip Joint Surg Br. 1985 May;67(3):402-5.
dislocation using the posterior lip augmentation device for the charnley hip 10. Watson P, Nixon JR, Mollan RA. A prosthesis augmentation device for the pre-
arthroplasty. J Arthroplasty. 2006 Sep;21(6):865-8. vention of recurrent hip dislocation. A preliminary report. Clin Orthop Relat Res.
5. Gungor T, Hallin G. Cup re-enforcement for recurrent dislocation after hip 1991 Jun;(267):79-84.
replacement. J Bone Joint Surg Br. 1990 May;72(3):525. 11. Williamson JB, Galasko CS, Rowley DI. Failure of acetabular augmentation for
recurrent dislocation after hip arthroplasty. Report of 3 cases. Acta Orthop Scand.
1989 Dec;60(6):676-7.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
50 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 51

MIS TOTAL HIP REPLACEMENT: THE GOOD,

THE BAD, AND THE UGLY (CC)

SYMPOSIA AR HIP
Moderator: John J. Callaghan, MD, Iowa City, IA, (a, c, e - DePuy)
There has been an explosion of information in the press and on the internet concerning
minimally invasive surgery of the hip. This symposium will concentrate on the scientific
data available concerning this topic.

I. Who is the Right Patient? Who is the Right Surgeon? Overview of MIS Use in the US
and Overview of Available Results
John J. Callaghan, MD, Iowa City, IA, (a, c, e - DePuy)

II. Anterolateral MIS Approach – Benefits, Procedure, Complications

William Hozack, MD, Philadelphia, PA (e - Stryker)

III. Posterolateral MIS Approach – Benefits, Procedure, Complications

Thomas P. Sculco, MD, New York, NY (n)

IV. 2 Incision Approach – Benefits, Procedure, Complications

Richard A. Berger, MD, Chicago, IL (a, e – Zimmer)

V. Marriage of MIS and Computer Assisted Surgery in THR - Benefits, Learning Curve and
Complications of MIS and CAS
Lawrence D. Dorr, MD, Inglewood, CA (a, c - Zimmer)

VI. Complications Associated With One Incision Surgery – Prevention and Treatment
Steven T. Woolson, MD, Palo Alto, CA (n)

VII. Complications Associated With Two Incision Surgery – Prevention and Treatment
Mark W. Pagnano, MD, Rochester, MN (c - Zimmer, DePuy)

VII. Discussion and Case Examples

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
51
SYM 07:Layout 1 1/12/07 11:39 AM Page 52

WHO IS THE RIGHT PATIENT? WHO IS THE RIGHT SURGEON?

OVERVIEW OF MIS USE IN THE US AND OVERVIEW OF
AVAILABLE RESULTS
John J. Callaghan, MD
SYMPOSIA AR HIP

In 2001 and 2002, several articles began to surface in the II. Who is the right surgeon?
orthopaedic literature concerning MIS total hip arthroplasty. A. The utilization of the total hip arthroplasty operation is
This came at a time when reports of the 30 year results of total on the rise and many surgeons will be required to han-
hip arthroplasty also became available which demonstrated dle this utilization.
excellent durability for the treatment of disabling hip arthritis. B. With conventional techniques, there is a wide variation
Since 2001, much more information is available in the literature in operative times and outcomes with total hip arthro-
and much more research is being performed to evaluate the plasty procedures. Will there be more or less variation
potential benefits and compromises related to MIS total hip with MIS procedures?
arthroplasty techniques. C. Will the learning curve be less severe with certain MIS
techniques?
I. Who is the right patient? Several questions need to be
III. How much MIS surgery is performed in total hip arthro-
answered to address this:
plasty procedures in the US today?
A. What are the demographics of patients undergoing total
A. Why is it difficult to track the prevalence of MIS hip sur-
hip arthroplasty today?
gery?
B. Do the changing demographics favor or disfavor the use
1. Few special devices utilized in these procedures
of MIS in total hip arthroplasty?
2. Definition is difficult
C. What are the economic issues in total hip arthroplasty
3. Only 11% of Hip Society members refer to MIS hip
today? Do the economics favor or disfavor the use of
surgery on their websites
MIS total hip arthroplasty?
D. Is one MIS approach more favorable for a certain popu-
lation (eg obese patients)?

REFERENCES: 5. Klein GR, Parvizi J, Sharkey PF, Rothman RH, Hozack WJ. Minimally invasive
1. Callaghan JJ, Templeton JE, Liu SS, Pedersen DR, Goetz DD, Sullivan PM, total hip arthroplasty: internet claims made by members of the Hip Society. Clin
Johnston RC. Results of Charnley total hip arthroplasty at a minimum of thirty Orthop Relat Res. 2005 Dec;441:68-70.
years. A concise follow-up of a previous report. J Bone Joint Surg Am. 2004 6. Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E,
Apr;86-A(4):690-5. Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total
2. Crowninshield RD, Rosenberg AG, Sporer SM. Changing demographics of hip replacement in the United States medicare population. J Bone Joint Surg Am.
patients with total joint replacement. Clin Orthop Relat Res. 2006 Feb;443:266- 2003 Jan;85-A(1):27-32.
72. 7. Parvizi J, Sharkey PF, Pour AE, Rapuri V, Hozack WJ, Rothman RH. Hip arthro-
3. Duncan CP, Toms A, Masri BA. Minimally invasive or limited incision hip plasty with minimally invasive surgery: a survey comparing the opinion of highly
replacement: clarification and classification. Instr Course Lect. 2006;55:195-7. qualified experts vs patients. J Arthroplasty. 2006 Sep;21(6 Suppl 2):38-46.

4. Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E,
Harris WH, Poss R, Baron JA. Association between hospital and surgeon proce-
dure volume and outcomes of total hip replacement in the United States
medicare population. J Bone Joint Surg Am. 2001 Nov;83-A(11):1622-9.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
52 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 53

MIS THA: ANTEROLATERAL APPROACH

William J. Hozack, MD

Indications inferomedially just superior to the iliopsoas tendon. This tech-

MIS THA implies less trauma. As such, the incidence of serious nique of capsular incision rather than excision maximizes expo-
complications - nerve injury, limb-length discrepancy, disloca- sure while maintaining the integrity of the capsule for hip sta-
tion, intrao-perative fracture - should not be greater than com- bility, and allows the patient full, unrestricted activity immedi-

SYMPOSIA AR HIP
plication rates associated with the “traditional approaches.” The ately after the surgery. Acetabular retractors, specially designed
surgical tenets of adequate exposure, minimal blood loss, and to facilitate the mini-incision approach, are placed in the fol-
respect for the soft tissues must apply to MIS techniques as well. lowing order: anterior, superior, inferior, and posterior. Before
The surgeon must have realistic expectations regarding incision reaming, the surgeon should identify the anterior and posterior
size relative to the patient’s body habitus and the surgeon’s abil- walls and columns, medial wall, and the acetabular notch. The
ity to attain adequate visualization for safe and proper compo- cup is generally under-reamed by 1 mm to obtain a press-fit.
nent insertion. The patient must have realistic expectations of The component is then inserted under direct visualization. A
physical change and must be counseled appropriately about the curved cup insertion device is available for component inser-
risks and benefits of MIS surgery. tion.
The acetabular retractors are then removed and the limb adduct-
Benefits
ed and externally rotated. A double-footed retractor is placed
The alternative to MIS THA is traditional hip replacement
posterior to the femur. A second double-footed retractor is
through anterior, anterolateral, or posterior approaches. The
placed lateral to the femur. The retractors, if properly placed,
advantage of the MIS anterolateral approach is direct visualiza-
will protect the soft tissues from injury during the reaming,
tion of muscle planes, acetabulum, and femur. No fluoroscopy
broaching, and insertion process. Exposure can be improved by
is required. The approach is familiar to surgeons and can be eas-
releasing the posterior capsule from the posterior femur to
ily adapted from the traditional technique. The approach can be
allow the limb greater adduction and to enhance proximal
easily extended as needed. All patients can be operated on using
femoral visualization. The entire circumference of the proximal
this approach. Because of retention of the posterior capsule, no
femur must be seen to assess version, axial stability, and rota-
hip precautions are required, so earlier and faster rehabilitation
tional stability as well as to allow early detection of fracture dur-
and return to work can occur.
ing femoral preparation and component insertion. The femur
is sequentially broached. The broach serves as a trial. A special
Technique
head-neck insertion device is available to make trial reduction
The length of the incision varies from 8 cm to 12 cm. The length
easier. The hip is then tested for stability, impingement, and
of the incision depends on surgical skill, patient weight, local
limb-length, and the final component is inserted.
adipose thickness, muscle mass, stiffness, and anatomy. A
“mobile window” is created at the level of the fascia that can be
Avoiding Pitfalls/Complications
shifted to maximize visualization.. The anterior and posterior
Surgeons should not attempt an immediate radical change in
borders of the gluteus medius are then identified. The anterior
operative technique but should progress through a series of
third of the gluteus medius, the entire gluteus minimus, and the
gradual steps aimed at reducing the size of the incision while
anterior half of the hip capsule are elevated as one flap. It is
maintaining a high priority on adequate exposure. The initial
important to limit invasion of the vastus lateralis because this
incision may be extended as needed to improve exposure and
minimizes bleeding, swelling, and pain. The flap is analogous to
spatial orientation, thus ensuring accurate component position-
a curtain; one can elevate the soft tissue as a “curtain” to expose
ing. Mistakes, such as reaming away the medial wall or the
the acetabulum and femur and then it can be repaired anatom-
acetabular supportive rim, are avoided because of direct visual-
ically. This is accomplished with minimal trauma to the abduc-
ization of the bony anatomy of the acetabulum.
tor muscles. The capsule is incised in two locations; superiorly
along the posterior border of the gluteus minimus tendon and

REFERENCES 6. Schurman DJ : Early outcome of total hip arthroplasty using the direct lateral vs.
1. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg Br 64(1):17- the posterior surgical approach. Orthopedics 1996;19:873-875.
19, 1982 7. Downing ND, Clark DI, Hutchinson JW, Colclough K, Howard PW : Hip abduc-
2. Masonis JL, Bourne RB: Surgical approach, abductor function, and total hip tor strength following total hip arthroplasty: A prospective comparison of the
arthroplasty dislocation. Clin Orthop 405:46-53, 2002 posterior and lateral approach in 100 patients. Acta Orthop Scand 2001;72:215-
220.
3. Barber TC, Roger DJ, Goodman SB, et al: Early outcome of total hip arthroplasty
using the direct lateral vs. the posterior surgical approach. Orthopedics 8. Hardinge K: The direct lateral approach to the hip. J Bone Joint Surg Br
19(10):873-875, 1996 1982;64:17-19.

4. Downing ND, Clark DI, Hutchinson JW, et al: Hip abductor strength following 9. Masonis JL, Bourne RB: Surgical approach, abductor function, and total hip
total hip arthroplasty: A prospective comparison of the posterior and lateral arthroplasty dislocation. Clin Orthop 2002;405:46-53.
approach in 100 patients. Acta Orthop Scand 72(3):215-220, 2001
5. Ahrengart L: Periarticular heterotopic ossification after total hip arthroplasty. Risk
factors and consequences. Clin Orthop 263:49-58, 1991

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
53
SYM 07:Layout 1 1/12/07 11:39 AM Page 54

LESS INVASIVE THR: THE POSTEROLATERAL APPROACH

Thomas P. Sculco, MD

The phrase “minimally invasive surgery” when performing a hip and with adequate exposure to correctly and safely perform the
arthroplasty has always seemed like an misnomer in that hip procedure. These techniques require customized instrumenta-
replacement surgery requires considerable alteration of anato- tion to facilitate these exposures as well as significant arthro-
my regardless of the exposure or technique. The phrase has been plasty training. Hypotensive regional anesthesia reduces bleed-
SYMPOSIA AR HIP

captured by the media and marketing spheres and has led in ing and facilitates the procedure.
many instances to public misinformation and expectation. The
Less invasive total hip replacement requires proper patient selec-
term “less invasive” describes more accurately what these proce-
tion to lessen rate of complication and promote a successful
dures encompass. In many surgical disciplines these less inva-
arthroplasty. Since surgical windows are more limited to insure
sive procedures have been adopted and it was inevitable that
proper visualization patients who have Body Mass Index of less
these concepts would influence arthroplasty surgery. These
than 30 are ideal. This applies to both single and two incision
techniques now are being utilized in many different approach-
procedures although those utilizing two incision techniques
es to the hip and knee and embody less deep dissection as well
have stated body mass is not an issue in the approach.
as a more conservative skin incision. Performing hip and knee
Certainly as body weight and obesity increase more extensive
arthroplasty through less traumatic exposures is feasible but the
exposures will be necessary. Through single incision less inva-
surgeon must use good judgment and be expert in his ability to
sive procedures graduated increase in exposure may be per-
perform these arthroplasties expeditiously and without com-
formed and this is not the case with two incision approaches.
promising the quality of the arthroplasty. The surgeon interest-
As a rule less invasive surgery is not recommended in patients
ed in performing these arthroplasties through more limited
with BMI >35. Additionally patients with complex primary hip
exposures must be experienced in arthroplasty surgery.
pathology are best performed through more extensive
The concept of performing a total hip replacement utilizing a approaches. These include patients with high riding hip dislo-
smaller incision and a more limited soft tissue exposure sur- cation (Crowe 4), severe hip ankylosis with or without protru-
faced during a hip replacement about eight years ago. The pro- sion and patients with severe soft tissue scarring secondary to
cedure was being carried out through the conventional postero- extensive prior hip surgery. An additional group that may pose
lateral approach and the incision length was approximately 8-9 a problem with visualization and soft tissue retraction is the
inches in length. The PGY 4 resident assisting me at the proce- heavy, well muscled, short stature usually male patient. In these
dure queried why the incision was as long as it was and he patients, especially if the hip joint is stiff, exposure is difficult
remarked that the lower portion of the incision was not being and exposures should be extended. Patients undergoing revi-
used. Indeed this was the case and on the subsequent hip sion hip surgery also are not ideal candidates for these less inva-
arthroplasty the incision was reduced by one inch without sive approaches as failed implant removal, bone grafting and
undue struggle. This led to a progressive decrease in incision augmentation usually require additional visualization.
length and soft tissue release during hip replacement surgery.
The use of more limited exposures for total hip arthroplasty
Subsequently instrumentation has been developed to facilitate
through modified posterolateral and a two incision fluorscopi-
exposure and acetabular and femoral preparation and the
cally assisted approach have generated considerable interest. I
length of the skin incision has been reduced to 3-4 inches in
do believe the two incision technique should be reserved for
length. Proper patient selection, surgical experience and instru-
those surgeons with particular interest in the technique as
mentation and careful dissection have led to satisfactory results
reported results have been inferior with this approach and the
in over 2500 patients to date.
learning curve may be significant. Poor information released
The key surgical concept is that the result of the arthroplasty through the media has raised patient expectations and inaccu-
should not be compromised by the surgical incision and expo- rately portrayed these procedures. Additionally pressure has
sure. If during the procedure visualization is poor there is an come to bear on orthopedic surgeons to perform these proce-
increased risk of suboptimal implant positioning and intraop- dures who are less experienced in arthroplasty. More extensile
erative femoral fracture may occur. If excessive or undue tension exposures must be used whenever needed to improve the out-
is being applied to the soft tissues about the hip femoral or sci- come of the procedure. However, the advantages of these more
atic neuropraxia may occur and this complication must be limited procedures are real and include more rapid rehabilita-
avoided. When attempting to reduce the length of the surgical tion, less blood loss, better cosmesis and in our series there has
incision it is recommended that the surgeon gradually limit the not been an increase in complications or implant malposition.
incision length in increments of ½ - 1 inch until a level is
reached where hip arthroplasty progresses without difficulty

REFERENCES 3. Sculco, TP, Jordan LC, Walter WL, Orthop. Clin North AM, 35, 137-142, 2004
1. Chimento, GF, Pavone V, Sharrock, N, Kahn, B, Cahill, J, Sculco, TP, J. 4. Sculco, TP, J. Arthroplasty, 19:78-80, 2004.
Arthroplasty, 20:139-144, 2005
2. Ogonda L, Wilson R, Archbold P, Lawlor M, Humprhreys P, O’Brien S, Beverland,
D. J Bone Joint Surg, 87, 701-10, 2005

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
54 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 55

DEVELOPMENT & DISSEMINATION OF THE

TWO-INCISION TECHNIQUE
Richard Berger, MD

The developed and disseminated of new approaches in joint 3.75%. The complication rate for these four surgeons in their
replacement impact can initial impact complications. next 825 cases was 1%. The three surgeons, who subsequently

SYMPOSIA AR HIP
learned this new technique, had a lower complication rate for
The first 400 cases from the four developers of a new THA
their first 300 cases, 1.9%. Furthermore, the learning curve for
approach that completed 100 cases each were prospectively
these subsequently trained surgeons was much less dramatic.
studied. The major complication rate (fracture, dislocation, re-
Lastly, the overall complication rate for these 1525 cases done
operation, or revision) from these 400 cases was analyzed and
by 7 different surgeons, at 6 different institutions was 1.9%.
then compared to 300 cases from three surgeons who were
trained by a developer and completed a formal cadaveric course. When new techniques are developed, a higher complication rate
In addition, the next 825 cases from the initial four developer is expected and must explained to patients. Formal IRB
surgeons were also analyzed. approval for any new technique is therefore warranted until the
documented complication rate reaches the standard procedure.
The developer’s complication rate was higher than their com-
Furthermore, disseminating these new techniques, with one-on-
plication rate for a standard THA until after they each did 35
one training and cadaveric courses, will likely result in a lower
cases. During the first 25 cases each (100 cases total) of the
complication rate than without such training. However, even
developer’s 400 cases, the complication rate was 8%. During
with proper training, disseminating a new technique will have a
the subsequent 300 cases, the complication rate for each 100
learning curve, which should be conveyed to patients.
cases was 6%, 1%, and 0%, respectively. The overall complica-
tion rate for the four surgeons in their first 100 cases each was

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
55
SYM 07:Layout 1 1/12/07 11:39 AM Page 56

MARRIAGE OF MIS AND COMPUTER ASSISTED SURGERY IN THR

Lawrence D. Dorr, MD

One of the concerns with MIS surgery is that the components Acetabular placement can be done with superb accuracy and
will not be placed accurately or reproducibly. In the studies reproducibility using the computer for instrumentation. One
published with the posterior mini incision there have not been great advantage of the computer is that the tilt of the pelvis is
reports of any greater number of outliers with component place- known. Once the tilt of the pelvis is known the acetabular posi-
SYMPOSIA AR HIP

ment than with long incision surgery. It seems that most of the tion can be adjusted for this tilt which then gives better acetab-
approaches do provide the surgeon the ability to use his/her ular coverage of the femoral component in different positions
usual landmarks in placing the acetabulum and the femur. that the patient will assume in using the hip after the operation.
Certainly the exposure of the acetabulum with good instru- The use of adjusted anteversion provides a more stable hip and
mentation is not different with a small incision than with a long a hip that should have greater durability because of reduction of
incision. The exposure of the femur is reduced because only the wear. In the studies that we have conducted the accuracy of
cut edge of the femur is seen if the quadratus is kept intact. With both inclination and anteversion with the computer is one
most long incision operations the entire metaphysis is visual- degree with no outlier greater than 5 degrees. In a comparative
ized by the surgeon. In fact, most surgeons use the lesser study to the accuracy of surgeons, an experienced surgeon had
trochanter as a point from which to measure for the femoral 33% of hips with either inclination or anteversion having an
neck cut. Therefore, with the femur it is critical that the femoral outlier greater than 5 degrees. Clearly the computer provides
component be aligned with the posterior cortex of the femur reproducibility and accuracy that the surgeon cannot match.
and that the lateral side of a broach be under the tip of the The use of the computer also gives confidence to the surgeon for
greater trochanter which means that the stem is not in any sig- the component positions with small incision surgery. In some
nificant varus. patients who have deep hips the ability to place the acetabular
component with confidence is greatly enhanced with computer
Computer technology simply is a high tech instrumentation. It
use.
provides both qualitative and quantitative knowledge for the
surgeon for the placement of the components. The femoral Our data of operations used performing a small posterior inci-
component is inflexible in its position within the femur when it sion (10+/- 2 cm) as randomized against long incisions showed
is correctly sized. With a non-cemented component it is critical improvement in the small incision surgery for both pain and
to align the posterior edge of the broach/implant with the pos- function in the early postoperative period. The power analysis
terior cortex of the neck. Attempts to antevert the implant with- for these statistics was greater than 0.8 so that there was con-
in the femur can result in fracture (and is probably the most vincing data. Most of these patients did have component posi-
common cause of fracture with implantation). The computer tioning with the computer and the component positions in this
can give the surgeon knowledge of the anteversion of the study were certainly equal to those we have published with long
femoral component in the femur. Tapered stems often do not incisions.
achieve anteversion of 10-15 degrees, particularly in men.
In summary, the advantage of computer navigation is that it is a
Relative retroversion of the femur, particularly at the level of the
sophisticated instrumentation that provides increased knowl-
cut femoral neck, is present in 20-25% of arthritic hips.
edge to the surgeon during placement of the components. This
Therefore, the knowledge of the anteversion of the femur is
increased knowledge improves the accuracy of component
valuable for the surgeon because the surgeon can then cus-
placement which improves stability and reduces wear. The only
tomize the anteversion of the cup to give correct combined
influence that computer navigation has on long term durability
anteversion. The assumption that the femoral component is in
of an operation is the improved component placement and the
10-15 degrees of anteversion, and targeting the acetabular com-
resultant reduction of wear. Its function is that of instrumenta-
ponent accordingly, can result in an insufficient combined
tion during the performance of the operation.
anteversion which can result in instability.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
56 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 57

COMPLICATIONS ASSOCIATED WITH MINIMALLY INVASIVE ONE

INCISION THR SURGERY
Steven T. Woolson, MD

One Incision MIS Literature Review — Less cup anteversion in Mini group
Randomized, Prospective, Blinded Studies — No data on complications

SYMPOSIA AR HIP
• Beverland – JBJS April, 2005 - Mini Posterior
One Incision MIS Literature Review Summary
— 100+ patients per group
• No Study reports any CLINICALLY SIGNIFICANT found in
— NO BENEFITS in pain, multiple function parameters,
any study
blood loss, length of stay, thigh swelling,
• 2 Studies show Higher Complication rate and/or more
— Postoperative CRP levels same –ie. MINI THR NOT
Component Malposition
LESS INVASIVE
• The Cons of MI THR outweigh the Pros
— Equivalent Complications
• PREVENTION OF COMPLICATIONS – MAKE INCISION 2-
• Wright -AAOS Annual Mtg, 2005 - Mini Posterior
3” LONGER
— NO BENEFITS in pain, blood loss, function, length of
• Standard-Incision THR Remains the Gold Standard
stay
— Equivalent Complications – There is No peer-review Scientific Evidence that there are any
— Randomized Prospective Study benefits to the patient from mini- incision THR after 5 years of
• Sculco, J Arthroplasty 2005 -Mini Posterior study
— NO BENEFITS except EBL (43cc) and Limp @ 6wks
Logical Deduction – Wait to do small incision THR until there
— Equivalent Complications
is evidence of benefits and safety
— Postop IL-6 levels Same –ie. MINI THR IS NOT LESS
INVASIVE Make the Smallest Incision that allows you to do a good job
— Surgeon has performed > 1000 mini posterior proce-
Measure the length of the incision at the end of the operation
dures
Mini-Incision - Controlled Matched Series – Same BMI
• deBeers-JA 2004 – Mini direct lateral
— NO BENEFITS except EBL (67cc)
— One Mini pt with late femoral fracture
• DiGioia- JA 2003 – Mini Posterior
— Higher HHS at 3-6mo with mini group
— Complication data absent
• Sharkey/Rothman/ JA 2006 Mini Lateral
— NO BENEFITS
— No complications in either group
— One Mini femoral revision @ 8 mo
Controlled Consecutive Studies – Mini Patients had lower BMI
than controls
• Woolson-JBJS 2004 –Mini Posterior Community
Surgeons
— NO BENEFITS
— Higher Complication and Malposition Rates
• Sculco- JA, 2004 – Mini Posterior
— NO SIGNIFICANT BENEFITS
— Same complication Rate
• Duncan and Masri – OCNA 2004 – Mini Anterolateral
— Better LOS with Mini but longer Surgical Time
• Rorabeck – CORR 2005 - Mini Direct Lateral Approach
— Little clinical difference
— Same Complication rate
• Goldstein – JBJS 2003 – Mini Posterior
— NO BENEFITS
— Same Complication Rate
• Skinner JA 2006 –(no BMI data) Mini Posterior
— More varus stems in Mini group

REFERENCES 2. Bal BS and Haltom JD. Early complications of primary THR performed with a
Peer Review Literature and AAOS Presentations two-incision minimally invasive technique. J Bone Joint Surg 87A: 2432-2438,
2005
1. Archibeck MJ and White RE Jr. Learning curve for the two-incision total hip
replacement. Clin Orthop 429:232-238, 2004. 3. Bal BS, Haltom JD, Aleto T and Barrett M. Early complications of primary total
hip replacement performed with a two-incision minimally invasive technique.
Surgical Technique. J Bone Joint Surg 88A Supplement 1, Part2, 221-233, 2006.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
57
SYM 07:Layout 1 1/12/07 11:39 AM Page 58

4. Berger RA. Total hip arthroplasty using the minimally invasive two-incision 17. Mardones RM, Pagano MW, Nemanich JP and Trousdale RT. Muscle damage
approach. Clin Orthop 417: 232-241, 2003. after THA done with the two-incision and mini-posterior techniques. Clin
5. Berger RA, Jacobs JJ, Meneghini RM et al. Rapid rehabilitation and recovery with Orthop 441:63-67, 2005
minimally invasive total hip arthroplasty. Clin Orthop 429:239-247, 2004 18. Mow CS, Woolson ST, Ngarmukos SG et al. Comparison of scars from total hip
6. Berry DJ, Berger RA, Callaghan JJ, Dorr LD, Duwelius PJ, Hartzband MA, replacements done with a standard or a mini-incision. Clin Orthop 441: 80-85,
Lieberman JR and Mears DC. AOA Symposium: Minimally invasive total hip 2005.
arthroplasty. JBJS 85A:2235-2246, 2003. 20. O’Brien PAL and Rorabeck CH. The mini-incision direct lateral approach in pri-
7. Chimento GF, Pavone V, Sharrock N et al. Minimally invasive total hip arthro- mary total hip arthroplasty. Clin Orthop. 441: 99-103 2005.
plasty: a prospective randomized study. J Arthroplasty 20: 139-144, 2005. 21. Ogonda L, Wilson R, Archbold P, Lawlor M, Humphreys P, O’Brien S and
8. Ciminiello M, Parvizi J, Sharkey PF, Eslampour A and Rothman RH. Total hip Beverland D. A minimal-incision technique in THA does not improve early post-
SYMPOSIA AR HIP

arthroplasty: is small incision better? J Arthroplasty 21:484-488, 2006. operative outcomes: a prospective randomized controlled trial. J Bone Joint Surg
87A: 701-710, 2005.
9. deBeer J, Petruccelli D, Zalzal P, et al. Single-incision, minimally invasive total
hip arthroplasty: length doesn’t matter. J Arthroplasty 19:945, 2004 22. Pagano MW, Leone J, Lewallen DG and Hanssen AD. Two-incision THA had
modest outcomes and some substantial complications. Clin Orthop 441: 86-90,
10. DiGioia AM, Plakseychuk AY, Levison TJ et al. Mini-incision technique for total 2005
hip arthroplasty with navigation. J Arthroplasty 18: 123-128, 2003.
23. Rachbauer F, Nogler MM, Krismer M et al. Minimal invasive total hip arthroplas-
11. Fehring TK and Mason JB. Catastrophic complications of minimally invasive hip ty via direct anterior single incision approach. Proceedings of AAOS Annual
surgery: a series of three cases. J Bone Joint Surg. 87A: 711-714, 2005. Meeting, 2005.
12. Goldstein WM, Branson JJ, Berland KA, et al. Minimal-incision total hip arthro- 24. Teet JS, Skinner HB and Khoury L. The effect of the “mini” incision in total hip
plasty. J Bone Joint Surg.; Supplement 4, 85A: 33, 2003. arthroplasty on component position. J Arthroplasty 21: 503-507, 2006.
13. Howell JR, Masri BA and Duncan CP. Minimally invasive versus standard inci- 25. Woolson ST, Mow CS, Syquia JF, et al. Comparison of primary total hip replace-
sion anterolateral hip replacement: a comparative study. Ortho clinics of NA ments performed with a standard incision or a mini-incision. J Bone Joint Surg.
35:153-162, 2004. 86A: 1353-1358, 2004.
14. Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH and Keggi KJ. Total 26. Wright JM, Crockett HC, Delgado S, et al. Mini-incision for total hip arthroplas-
hip arthroplasty through a minimally invasive anterior surgical approach. J Bone ty: a prospective, controlled investigation with 5-year follow-up. J Arthroplasty
Joint Surg.; Supplement 4; 85A: 39, 2003. 19:538-545, 2004.
15. Labovitch RS, Bozic KJ and Hansen E. An evaluation of information available on 27. Wright JM, Rosse S, Rosse D, Lyman S. Comparison of abridged to standard
the internet regarding minimally invasive hip arthroplasty. J Arthroplasty 21: 1-5, incision total hip replacement: a prospective, randomized, blinded investigation.
2006. Proceedings of AAOS Annual Meeting, Washington, DC, February 2005.
16. Lawlor M, Humphreys P, Morrow E, Ogonda L, Bennett D, Elliott D and
Beverland D. Comparison of early postoperative functional levels following total
hip replacement using minimally invasive versus standard incisions. A prospec-
tive randomized blinded trial. Clin Rehabilitation 19:465-474, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
58 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 59

THE 2-INCISION THA: ITS ROLE IN 2007

Mark W. Pagnano, MD

I. MIS two-incision THA introduced in 2002 damage to the abductors, the external rotators or both
A. Substantial media coverage 2. The extent of damage to the abductors was significant-
B. Substantial patient and surgeon interest ly greater with the 2-incision technique than with
C. No peer reviewed scientific data mini-posterior technique

SYMPOSIA AR HIP
II. MIS two-incision THA claims
A. No muscle or tendon damage
B. It was suggested that with a little bit of skill, a little bit of
practice and a lot of patience the operation could be
done without cutting or detaching any muscle or tendon
C. Rapid rehabilitation
D. Outpatient surgery
III. Initial reports from the developers
A. Berger RA: THA using the minimally invasive two-inci-
sion approach. CORR 417:232-241, 2003.
1. 100 2-incision cases
2. 100% free of dislocation Figure A: the posterior hip anatomy is such that there is no interval
3. 100% bone ingrown between the gluteus minimus and the short external rotators.
4. 100% free of reoperation
5. 100% free of complication (other than 1 proximal
femoral fx)
6. 100% free of readmission after d/c same day or next day
7. 100% free of complications at home
B. Berger RA et al.: Rapid rehabilitation and recovery with
minimally invasive total hip arthroplasty. CORR
429:239-247, 2004.
1. 100 2-incision cases done as first case of the day
2. 100% met d/c criteria by 23 hours postop
3. 97% met d/c criteria the day of surgery
4. Mean 6 days to: d/c crutches, narcotics, resume driving
5. Mean 8 days to return to work Figure B: demonstrates that the piriformis tendon actually overlies a
6. Mean 9 days to d/c cane portion of the gluteus minimus, making it impossible to blindly ream
7. Mean 10 days to resume all ADLs the femoral canal without causing some damage to the minimus, the
8. Mean 16 days to walk ½ mile piriformis or both. If the surgeon moves anterior to protect the piri-
C. Berrry DJ, Berger RA, Callaghan JJ et al: Minimally inva- formis, then more of the minimus is damaged and vice-versa.
sive THA: development, early results and critical analysis.
Presented at the Annual Meeting of the AOA, Charleston,
SC June 14, 2003. JBJS 85-A:2235-2246, 2003.
1. Combined data from surgeons Berger, Duwelius,
Hartzband and Mears
2. 375 patients; mean age of 56; 2 of 3 patients are male;
weight 185 pounds
3. 5 major complications ( 1.3 %)
4. 8 minor complications ( 2.1 %)
IV.Subsequent Data from non-developers
A. Archibeck MJ and White RE, Jr: Learning curve for the
two-incision total hip replacement. CORR 429:232-238, Figure C: When the gluteus medius is also considered it becomes clear
2004. that placing a reamer blindly through a posterior stab incision and then
1. Tracked the early experience of 159 surgeons trained maneuvering it posterior to the medius and then anterior to the piri-
in the two-incision technique formis will result in muscle damage. Most of that damage will be to the
2. Key complications did not decrease over the first 10 minimus, with variable amounts of damage to the medius, the piri-
cases formis and the short external rotators.
3. If a learning curve exists then it must extend beyond C. Pagnano MW, Leone J, Lewallen DG, Hanssen AD. Two-
10 cases incision THA had modest outcomes and some substan-
4. Operative time did decrease over first 10 cases tial complications. CORR December, 2005.
B. Mardones R, Pagnano MW, Nemanich JP, Trousdale RT. 1. 80 consecutive patients with primary DJD had a 2-
The Hip Society Frank Stinchfield Award: Muscle damage incision THA with technique of Mears and Berger
after total hip arthroplasty done with the two-incision, 2. Deviated from recommended protocol by using a
mini-posterior techniques. CORR December, 2005. proximally porous coated stem instead of extensively
1. Cadaveric study clearly demonstrated that it was not coated stem
possible to do 2-incision THA without substantial
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
59
SYM 07:Layout 1 1/12/07 11:39 AM Page 60

3. 14% prevalence of complications including 3 postop V. Emerging 2-Incision Data

femur fxs requiring revision; 2 nerve palsies; 4 calcar A. Pagnano MW, Meneghini RM, Leone J: A Prospective
cracks intraoperatively. Randomized Clinical Trial Shows That Two-Incision
4. Key fact: most major complications in this study Total Hips Recover More Slowly Than Mini-Posterior
occurred in elderly, obese females Total Hips
5. Modest early function in patients without complica- 1. 72 patients with primary degenerative arthritis of the
tions hip
a. 12 days to d/c narcotics 2. Randomized with a computer program to ensure
b. 14 days to resume ADLs dynamic balancing of the 2 groups with respect to
SYMPOSIA AR HIP

c. 22 days to d/c walker age, sex and BMI

d. 36 days to d/c cane 3. Early functional results based on functional mile-
e. 36 days to return to driving stones
f. 40 days to walk ½ mile 4. The 2-incision patients recovered more slowly than
D. Pagnano MW, Meneghini RM, Trousdale RT, Hanssen: the mini posterior patients as measured by the mean
Patients preferred a mini-posterior THA over a contralat- time to discontinue a walker or crutches, to discontin-
eral two incision total hip. Presented at Interim Meeing ue all ambulatory aids, and to return to normal daily
of Hip Society Sept. 2005 and Annual Meeting of AAHKS activities.
Nov. 2005. B. Pagnano MW, Meneghini RM, Kaufmann K et al: A
1. 26 patients had staged bilateral THA with a 2-incision Prospective Randomized Gait Analysis study of 2-
THA on one side and a mini posterior THA on the Incision versus mini-posterior THA.
other 1. 20 patients with primary degenerative arthritis of the
2. Six months after the second THA was done patients hip
were asked to compare the early functional result and 2. Preop comprehensive gait analysis including level
state a preference for one hip or the other walking and stair climbing
3. 16 of 26 patients clearly preferred the mini-posterior 3. Postop comprehensive gait analysis at 8 weeks
THA 4. This study dispels the notion that the early functional
a. 8 of those patients preferred mini because of quick- outcome after 2-incision THA is dramatically better
er recovery than that after other methods of THA. Instead, when
b. 4 preferred mini because of better cosmesis there was a difference in strength or gait parameters it
c. 4 preferred mini because both better cosmesis and was the mini-posterior patients who tended to have
quicker recovery the quicker recovery.
4. 8 of 26 preferred the 2-incision THA; 2 had no prefer-
VI. Conclusions Two-Incision THA in 2007
ence
A. To date there is no scientific data that shows a two-inci-
a. all 8 patients who preferred 2-incision said it was
sion approach is functionally better than other THA
because of quicker recovery; no patient thought the
approaches
cosmetic result was better with 2 incision tech-
B. Basic science cadaver work and anatomic studies dispel
nique.
the notion that two-incision THA can be done without
b. 2 patients were equally happy with both hips and
cutting or damaging muscle or tendon
did not care about the cosmetic result.
C. For many surgeons the prevalence of complications is
5. Conclusion: The added technical difficulty of the 2-
high when adopting the two incision technique
incision THA was not rewarded with better patient-
D. Elderly, obese female patients appear to be at greater risk
rated functional or cosmetic result.
for complications with the 2-incision technique
E. Bal BS et al.: Early complications of primary total hip
E. Patients who have had a 2-incision THA and a contralat-
replacement performed with a two-incision minimally
eral mini-posterior THA more often preferred the mini-
invasive technique. JBJS 87-A:2432-2438, 2005.
posterior THA
1. 89 consecutive patients had 2-incision THA
F. Compared to a mini-posterior THA, the added technical
2. 10% reoperation rate (2 femur fxs, 4 subsidence, 1
difficulty of the MIS two-incision hip has not been
dislocation)
rewarded with a better functional outcome or a better
3. 25% prevalence of lateral femoral cutaneous palsy
cosmetic result when applied to similar groups of
4. Prevalence of complications was markedly higher
patients.
than the surgeons historical control of mini-posterior
THA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
60 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 61

CONTROVERSIAL ISSUES AND HOT TOPICS

IN PRIMARY TOTAL KNEE REPLACEMENT

SYMPOSIA AR KNEE
(K)
Moderator: William J. Maloney, MD, Stanford, CA (a - DePuy, Metronics, c - Zimmer, Wright Medical)

Total and partial knee arthroplasty has proven to be a reliable procedure for relief of pain
providing improved function. Less invasive techniques have been developed and are being
adopted for widespread use. This symposium will review the various techniques now being
performed as well as discuss potential pitfalls.

I. Fixation: Now and in the Future

Cement: The Gold Standard – Daniel J. Berry, MD, Rochester, MN
(a, c – DePuy, a – Stryker, Zimmer)
Cementless: As Good as Gold – Aaron A. Hofmann, MD, Salt Lake City, UT
(a – Zimmer)
New Surfaces and Surface Treatments – Paul F. Lachiewicz, MD, Chapel Hill, NC
(a, e – Zimmer)

II. The PCL and Predictable Function

Retain – CR – Harry E. Rubash, MD, Boston, MA (a, b – Zimmer)
Sacrifice – PS – Robert Booth, MD, Philadelphia, PA (c - Zimmer)

III. The Tibial Component

Fixed Bearing: Metal Backed and All Poly – Arlen D. Hanssen, MD, Rochester, MN
(c, e – Stryker)
Mobile Bearing – John J. Callaghan, MD, Iowa City, IA (a, c, e – DePuy)

IV. DVT Prophylaxis: What is Necessary?

Chemical – Daniel J. Berry, MD Rochester, MN (a, c – DePuy, a – Stryker, Zimmer)
Mechanical – Paul F. Lachiewicz, MD, Chapel Hill, NC (a, e – Zimmer)

V. Gender Specific Implants: Marketing Hype or Anatomic Fact?

Pro – Robert Booth, MD, Philadelphia, PA (c - Zimmer)
Con – Merrill A. Ritter, MD,Indianapolis, IN (a – Biomet)

VI. Navigation: Not Ready for Prime Time

Disagree – Aaron A. Hoffmann, MD Salt Lake City, UT (a – Zimmer Corp.)
Agree – John J. Callaghan, MD Iowa City, IA (a, c, e – DePuy)

VII. Less Invasive TKR

Definite Benefit – Alfred J. Tria, MD, Princeton, NJ
(c – Zimmer, e – IMP, Smith and Nephew)
Two Steps Forward, One Step Back – Arlen D. Hanssen, MD, Rochester, MN
(c, e – Stryker)
It’s the Pain Control – Chitranjan S. Ranaswat, MD, New York, NY
(a – Stryker Howmedica, a, c – DePuy)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
61
SYM 07:Layout 1 1/12/07 11:39 AM Page 62

CEMENTED TOTAL KNEE ARTHROPLASTY FIXATION:

THE GOLD STANDARD
Daniel J. Berry, M.D.

I. Introduction 1. Speed (?)

SYMPOSIA AR KNEE

A. Goals of total knee arthroplasty 2. No cement to deal with (advantages in small inci-
1. Reliable pain relief and improvement in function sions)
2. Durability 3. Once fixed may be more durable
B. Drawbacks
II. Cemented Fixation
1. Risk of failure of initial fixation
A. Pain relief
a. Pain
1. Reliable in all series – good initial fixation
b. Unhappy patient
B. Durability
c. Difficult to evaluate
1. 90-95% survivorship in multiple series at 15(+) years
2. No studies of uncemented implants have demonstrat-
2. When survivorship free of aseptic implant loosening is
ed better long-term fixation results than cement to
considered survivorship is even higher.
date.
C. Other advantages of cemented fixation
3. Technically more demanding
1. Technically straight forward: bone cuts not as
4. Higher cost
demanding as uncemented
2. Cost: lower than uncemented IV.Conclusions
3. Evaluation of the painful TKA: It is easier to tell if a A. At present cemented TKA fixation is the gold standard
cemented TKA has loosened and needs revision than B. Uncemented fixation needs to gain higher reliability of
an uncemented TKA bone ingrowth and simpler more reproducible surgical
technique to compete successfully with cement. This may
III. Uncemented Fixation
happen in the future.
A. Does have some advantages

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
62 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 63

CEMENTLESS TKA: AS GOOD AS GOLD

Aaron A. Hofmann, MD

Cementless fixation of TKA continues to demonstrate durabili- femoral and one tibial component required revision. The patel-
ty. This author reviewed 300 consecutive knees (238 patients) lar component survivorship at 10 years was 95.1%. All patellar
that had undergone arthroplasty with a cementless prosthesis revisions were attributed to edge wear. Subsequent operative
from 1985 to 1989, 176 knees (141 patients) were available for and design changes, including patellar component medializa-

SYMPOSIA AR KNEE
follow up at an average of 12 +/- 1 years after the operation. tion and countersinking, have decreased the incidence of patel-
Knee function was improved significantly. Modified Hospital lar revision. The long-term results of this cementless knee sys-
for Special Surgery knee scores improved from 59.1 +/- 13.2 tem compare favorably with those of cemented systems.
points preoperatively to 97.8 +/- 4.7 points at last follow-up. At Cementless designs will provide excellent and predictable long-
last follow-up, knee range of motion averaged 0 degrees +/- 2 term clinical results in active patients.
degrees to 120 degrees +/- 10 degrees. Implant survival was
In another recent review of cementless knees in <50 year-old
93.4% (including infection and simple polyethylene exchanges)
patients, there were no revisions for loosening or implant failure.
and 95.1% (excluding infection and simple polyethylene
The polyethylene remained the weak link. Radiographically,
exchanges) at 10 years when applying the Kaplan-Meier survival
there were no loose implants. Cementless fixation in the young
analysis, using loose components, revision, or both as failure
patient with high physical demands was clinically reliable.
criteria. Besides the three revisions for infection, only two

REFERENCES 2. Hofmann AA, Heithoff SM, Camargo M. (2002). Cementless total knee arthro-
1. Hofmann AA, Evanich JD, Ferguson RP, Camargo MP. (2001). Ten- to 14-year plasty in patients 50 years or younger. Clin Orthop Relat Res, (404), 102-7.
clinical follow-up of the cementless Natural Knee system. Clin Orthop, (388),
85-94.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
63
SYM 07:Layout 1 1/12/07 11:39 AM Page 64

NEW SURFACES AND SURFACE TREATMENTS:

IMPROVING THE ODDS FOR CEMENTLESS FIXATION
Paul F. Lachiewicz, M.D.

• Goal: Can the success of cementless TKA be impvoed and – no OP-1 FDA approved for knee arthroplasty
SYMPOSIA AR KNEE

made “equivalent” to cemented TKA and cementless THA? – Potential – enhance ingrowth
• Strategies for improving fixation – bone ingrowth of fill defects – primary, revision TKA
cementless TKA components – Clinical studies needed before widespread use in cement-
less TKA
1. Bioactive Coatings
Hydroxyapatite-coatings (HA) 2. New Ingrowth Materials
Osteogenic proteins (OP-1) • Trabecular Metal – Porous Tantalum
Bobyn et al JBJS Br 1999
2. New ingrowth materials
Characteristics
Trabecular metal-tantalum
- Pure elemental tantalum (Ta73)
3. Decrease polyethylene wear and osteolysis - Porosity ~ 75%; pore size ~ 430 mm
New polyethylene (highly crossed linked) - High friction – micro-spike fixation
New femoral component coating (Zirconium) - Osteoconductive; rapid bone ingrowth
- Low stiffness; reduced stress shielding
1. Bioactive Coatings
- High strength
• HA Coating TKA
? The “Holy Grail” of uncemented TKA?
Most biomechanical and clinical studies in Europe, Asia,
• Total Knee Arthroplasty Component
Australia
– Monoblock TM tibia
• RSA studies
- PS or PCR designs
1. Nelissen et al JBJS 1998
- Initial stability – hexagonal post (4)
– micromotion of HA-coated tibial component signifi-
- Compression –molded poly interlocked with TM (no
cantly less than noncoated uncemented components:
backside wear)
equivalent to cemented components
- Reduced tendency for lift-off in coronal plane
– 2 yr subsidence data HA-cemented
• TM patella 2 designs
2. Carlson et al Acta Orthop 2005
– Monoblock; hexagonal post
5 year data
– Augmentation – revision component
– cemented more stable than uncemented
• TM coated femoral component
– HA-coated tibial comp migrated less than uncoate
– in development
porous tibia
Clinical Results
• Clinical Studies
• Bobyn et al AAOS 2004
1. Cross & Parish JBJS Br 2005
• TM tibia: 95 knees, 2 yr follow-up
HA coated CoCr beaded femoral comp
– No revisions
HA coated titanium alloy tibial comp
– No new or progressive RLL
4 press fit lugs and screws
• TM patella – monoblock: 69 knees, 2 yr follow-up
1000 knees; mean age 68 yrs; mean f/u 6.6 yrs
No revisions
10 yr survival 99%
• TM revision patella
No aseptic loosening
Nasser et al J Arthroplasty 2004
2. Oliver et al JBJS Br 2005
11 knees; mean 32 month follow-up
HA coated I-B II
Only 1 failure
138 knees; mean f/u 11 yrs
93% survival; 6 revisions for loosening 3. Decrease Polyethylene Wear and Osteolysis
3. Tai & Cross JBJS Br 2006 • Cementless TKA will be successful long-term only if there is
HA coated, PCR knee major improvement in polyethylene wear which should
118 knees; mean age 50.7 years; mean f/u 7.9 yrs lower or eliminate the risk of late osteolysis
2 revisions for tibial loosening • These strategies include:
1 revision for poly wear – Better compression molded poly
Conclusions: Results promising: ? late osteolysis – Monoblock tibial components
Additional studies needed – Highly cross linked polyethylene
• Osteogenic Protein – 1 (rhOP-1) – Oxidized zirconium femoral component
– combined with collagen carrier, allograft or autograft (reduced wear 42% compared to CoCr femur in knee
– powerful osteoinductive agent wear simulator.
– preclinical evaluation – canine defects; enhance fixation Ezzet et al Clin Orthop 2004)
of titanium implants in femur

REFERENCES 2. Kray MJ, Goldberg VM. Hydroxyapatite. Surgical Techniques in Total Knee
1. Lachiewicz PF. Cement versus cementless total knee replacement: is there a Arthroplasty. Eds. Tria, AJ and Scuderi GR, Springer, New York, NY 2002.
place for cementless fixation in 2001? Curr Opin Orthop 2001, 12:33-36.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
64 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 65

3. Nelissen RGHH, Valstar ER, Rozing PM. The effect of hydroxyapatite on the 9. Lind M, Overgaard S, Song Y, Goodman SB, Bünger C, S?balle K. Osteogenic
micromotion of total knee prostheses. A prospective, randomized, double-blind protein 1 device stimulates bone healing to hydroxyapaptite-coated and titanium
study. J Bone Joint Surg 1998, 80-A(11):1665-1672. implants. J Arthroplasty 2000, 15(3):339-346.
4. Carlsson A, Borkman A, Besajakov J, Onsten I. Cemented tibial component fixa- 10. Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of
tion performs better than cementless fixation: a randomized radiostereometric bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J
study comparing porous-coated, hydroxyapatite-coated and cemented tibial com- Bone Joint Surg Br 1999, 81-B(5):907-914.
ponents over 5 years. Acta Orthop. 2005, 76(3):362-369. 11. Bobyn JD, Tanzer N, Krygier JJ, Lewallen DG, Hanssen AD, et al. Clinical valida-
5. Cross MJ, Parish EN. A hydroxyapatite-coated total knee replacement. tion of a structural porous tantalum biomaterial for adult reconstruction. AAOS
Prospective analysis of 1000 patients. J Bone Joint Surg Br 87-B(8):1073-1076. 2004 Poster.

SYMPOSIA AR KNEE
6. Oliver MC, Keast-Butler OD, Hinves BL, Shepperd JAN. A hydroxyapatite-coated 12. Poggle RA, Wood JE. Preliminary clinical and radiographic results of porous tan-
Insall-Burstein II total knee replacement. 11-Year Results. J Bone Joint Surg Br talum in primary TKA. Knee arthroplsty: Engineering functionality, IMechE, The
2005, 87-B:478-482. Royal College of Surgeons, London, United Kingdom, April 7-9, 2005.
7. Tai CC, Cross MJ. Five- to 12-year Follow-up of a hydroxyapatite-coated cement- 13. Nasser S, Poggie RA. Revision and salvage patellar arthroplasty using a porous
less total knee replacement in young, active patient. J Bone Joint Surg Br 2006, tantalum implant. J Arthroplasty 19(5):562-572.
88-B:1158-1163. 14. Ezzet KA, Hermida JC, Colwell CW, D’Lima DD. Oxidized zirconium femoral
8. Cook SD, Barrack RL, Patron LP, Salkeld SL. Osteogenic Protein-1 in knee arthri- components reduce polyethylene wear in a knee wear simulator. Clin Orthop
tis and arthroplasty. Clin Orthop 2004, 428:140-145. 2004, 428:120-124.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
65
SYM 07:Layout 1 1/12/07 11:39 AM Page 66

POSTERIOR CRUCIATE-RETAINING TKA REMAINS THE

STANDARD
John Franklin, MD, Harry Rubash, MD

Proponents of both cruciate-retaining (CR) and posterior-stabi- ethylene insert have the potential to result in a higher rate of
SYMPOSIA AR KNEE

lized (PS) total knee prostheses can point with equal enthusi- loosening of the implants.2 In the knee requiring an extensive
asm to the multiple studies documenting long-term clinical suc- medial or lateral release, the resultant increase in the flexion
cess with either type of implant. However, the CR knee offers space can allow the femur to jump the tibial post.6 Yet even in
advantages in terms of indications, surgical technique, kinemat- the well-balanced knee, the post can be a source of potential
ics, and design over its PS counterpart and as such should be morbidity from impingement and wear.7 Forces applied to the
considered for use in most patients requiring TKA. post can also be transmitted through to the interface between
the polyethylene and tibial tray, producing backside wear.8
Long-term survival results with CR knees are outstanding. At
follow-up ranging from ten to fifteen years, reported implant Studies of function and kinematics of the CR knee have
survival is 93-99%, matching or surpassing long-term results shown equal or superior results to the PS design. The CR knee
reported for PS knees.1-3 These same authors report excellent is more biomechanically efficient as it requires less muscle activ-
long-term results of CR knees with sustained improvement in ity during walking on both level ground as well as stair climb-
Knee Society scores and range of motion in patients with a range ing than the PS knee.9 In addition, CR knees do not have the
of diagnoses and deformities. Loosening or the presence of sig- potential source of implant loosening associated with the varus
nificant radiolucencies under surviving implants are rare find- and flexion moments of the PS design.9 Problems associated
ings. Recent prospective, randomized studies comparing clini- with CR designs in the past, such as patellar tracking and poly-
cal outcome in patients with either CR or PS knees can tell no ethylene wear, have been minimized through modification of
significant differences between the groups.4,5 The results of the components. Patellofemoral tracking and deep flexion have
these studies confirm that the indications for the CR knee are been improved and hold promise for even better functional
broad and that excellent results with with CR knees are repro- results.10,11 PCL-retaining knee designs have long been con-
ducible and reliable. With results of CR and PS knees being oth- sidered to have a more physiologic femoral rollback. In vitro
erwise equal, the benefits of retaining the ligament, eliminating robotic analysis of high-flexion designed components confirms
the problems of the post, and improved kinematics give CR the importance of the PCL in facilitating posterior femoral roll-
prostheses the edge. back.12
Intraoperatively, the ligament is critical in producing a well-bal- CR knee design offers distinct advantages over PS in technique,
anced knee. The PCL functions as a checkrein of the flexion gap, biomechanics and design over PS, yet in cases of significant
and as a result the ligament prevents further distal femoral deformity or inflammatory disease, we acknowledge that one
resection during flexion-extension gap balancing. Retention of might consider another option. Lombardi, et al reported excel-
the ligament also allows more accurate and reproducible lent clinical results using an algorithm to determine the choice
restoration of the normal joint line. CR prostheses also abide of implant based on deformity and the disease process.13
by the reconstructive principle of bone preservation by sparing Surgeons should carefully consider each patient’s individual
femoral intercondylar bone, thus theoretically benefiting the needs when making an implant choice. Just as men and women
patient and surgeon during any later procedure. exhibit differences in knee anatomy and mechanics, there is sig-
nificant variation within the spectrum of degenerative knee dis-
Another problem of PS knees is related to a more conform-
ease that may preclude the selection of one prosthesis for all
ing polyethylene insert and long-term wear of the post. In the
knees. However, the superior results of the CR total knee arthro-
PS knee, the increased constraint and conformity of the poly-
plasty are undeniable.

REFERENCES: 7. Puloski SKT, McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB. Tibial post
1. Dixon MC, Brown RR, Parsch D, Scott RD. Modular fixed-bearing total knee wear in posterior stabilized total knee arthroplasty. J Bone Joint Surg Am. 2001;
arthroplasty with retention of the posterior cruciate ligament. J Bone Joint Surg 83(3):390-397.
Am. 2005; 87(3):598-603. 8. Li G, Papannagari R, Most E, Park SE, Johnson T, Tanamai L, Rubash HE.
2. Ritter MA, Berend ME, Meding JB, Keating EM, Faris PM, Crites BM. Long-term Anterior tibial post impingement in a posterior stabilized total knee arthroplasty.
followup of anatomic graduated components posterior cruciate-retaining total J Orthop Res. 2005; 23(3):536-541.
knee replacement. Clin Orthop. 2001; 388:51-57. 9. Dorr LD, Ochsner JL, Gronley J Perry J. Functional comparison of posterior cruci-
3. Barrington JW, Sah AP, Freiberg AA, Malchau H, Burke DB. Minimum 10-year ate-retained versus cruciate-sacrificed total knee arthroplasty. Clin Orthop. 1988;
results with a contemporary cruciate-retaining total knee arthroplasty. Presented 236:36-43.
at 36th Annual Advances in Arthroplasty course; 2006: October6, Boston, MA. 10. Mont MA, Yoon TR, Krackow KA, Hungerford DS. Eliminating patellofemoral
4. Clark CR, Rorabeck CH, MacDonald S, MacDonald D, Swafford J, Cleland D. complications in total knee arthroplasty. J Arthroplasty. 1999;14(4):446-455.
Posterior-stabilized and cruciate-retaining total knee replacement: a randomized 11. Most E, Li G, Sultan PG, Park SE, Rubash HE. Kinematic analysis of conventional
study. Clin Orthop. 2001; 392:208-212. and high-flexion cruciate-retaining total knee arthroplasties: an in vitro investiga-
5. Misra AN, Hussain MRA, Fiddian NJ, Newton G. The role of the posterior cruci- tion. J Arthroplasty. 2005; 20(4):529-535.
ate ligament in total knee replacement. J Bone Joint Surg Br. 2003; 85(3):389- 12. Most E, Zayontz S, Li G, Otterberg E, Sabbag K, Rubash HE. Femoral rollback
392. after cruciate-retaining and stabilizing total knee arthroplasty. Clin Orthop. 2003;
6. Mihalko WM, Krackow KA. Posterior cruciate ligament effects on the flexion 410:101-113.
space in total knee arthroplasty. Clin Orthop. 1999; 360:243-250. 13. Lombardi AV, Mallory TH, Fada RA, Hartman JF, Capps SG, Kefauver CA, Adams
JB. An algorithm for the posterior cruciate ligament in total knee arthroplasty.
Clin Orthop. 2001; 392:75-87.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
66 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 67

SACRIFICE AND SUBSTITUTE FOR THE PCL

Robert E. Booth, Jr., MD

FACT : PS TKA ROM greater than CR in majority of studies, FACT: PS TKA has greater simplicity and success, especially

SYMPOSIA AR KNEE
internal and external to industry. for lower volume surgeons.
FACT: PS TKA stability greater – PS dislocation rate 0.15% vs. FACT: PS TKA has superior and consistent kinematic design,
100% subluxation with CR. not altered annually in response to instability and
osteolysis like CR TKA.
FACT: PS TKA survival rates equal or greater in all series.
Best long-term survival. FACT: PS TKA has consistent and predictable rollback, unlike
CR TKA, which minimizes poly wear.
FACT: PS TKA success rates greater in combined deformities
over 20°. Handles a wider and more difficult range of FACT: PS TKA, despite early reports, now confirmed to have
problems. equal gait and stair climbing results.
FACT: PCL preservation does not provide better propriocep- FACT: PS TKA mid-range laxity is less troublesome than CR
tion in CR TKA’s. mid-range stiffness.
FACT: Shallow trochlear box minimizes femoral bone loss in FACT: PS TKA now fastest-rising design, soon to overtake CR
PS TKA, while CR design mandates greater tibial bone nationally and worldwide.
resection.
CONCLUSION:
FACT: CR & PS designs now both accommodate patellar
PS TKA is easier, more reliable, longer lasting, more stable, and
non-resurfacing.
more mobile than CR-TKA fixed bearing designs. Why would
FACT: PS TKA has 3 times greater (3mm. vs. 9mm) accom- you not use a PS-TKA???
modation of joint line alteration than CR.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
67
SYM 07:Layout 1 1/12/07 11:39 AM Page 68

FIXED-BEARING TKR ARE THE STANDARD

Arlen D. Hanssen, MD

1) Fixed Bearing TKR Range of Motion: 5 other comparative studies have revealed no
Since introduction, fixed bearing implants have represented the benefit to the RP TKR as compared with fixed bearing
standard for implant design. Design changes have included designs.3,9,16,21,28
modularity, articular surface geometry, and improvement of tib-
SYMPOSIA AR KNEE

Reduced Forces Promote Bone Ingrowth: although there have

ial baseplate locking designs. Although these modifications
been no studies which scientifically support this position, there
have been in response to observed clinical problems, the design
are none that refute this either. One recent study casts some con-
feature of allowing motion between the tibial insert and plat-
cern about this hypothesis.1
form represented a significant departure in knee design. The
unique problems related to the “rotating” design change consti- 73 cementless mobile-bearing TKR performed for OA with only
tute the basis for establishing the fixed-bearing design as the mild or moderate deformity. Six of 73 (8%) underwent tibial
continued gold standard for TKR. component revision for symptomatic subsidence and failure of
ingrowth compared to 0/66 revisions in the cemented group
2) Mobile-Bearing TKR (P<.05). The results do not support the hypothesis that mobile-
The original design intent of “rotating” TKR was to provide bearing TKA imparts the advantage of reliable tibial bone
low constraint forces with low contact stresses (LCS) to allow ingrowth.
nearly normal joint articulation and loading as well as long-
term wear resistance of the implants. 6 Reduced Osteolysis / Wear:
Although it has been assumed that this benefit has been realized
Proposed Advantages of RP-TKR by patient with an RP-TKR, there is no proof that this assump-
• Improved patellofemoral mechanics (accommodation of tion is correct. Others have expressed concern that there may be
small mismatches in the rotational position of the tibial concerns with regards to polyethylene particle size found with
and femoral components) RP-TKR.
• Increased ROM
Study 1. Osteolysis induced by ultrahigh molecular weight
• Reduced forces promote bone ingrowth
polyethylene wear debris has been recognized as the major
• Reduced osteolysis / wear
cause of long-term failure in total joint arthroplasties. The
• TKR for young, active patients
prevalence of intraoperatively identified osteolysis during pri-
(Substantiation of these claims requires excellent compara- mary revision surgery was much higher in mobile bearing knee
tive studies) replacements (47%) than in fixed bearing knee replacements
(13%).14
Study 1. A prospective randomized study (240 pts) with a sin-
gle PS femoral design.18 All patients had OA. Preop ROM and Study 2. Mobile bearing knee implants tend to produce small-
stair climbing scores were not significantly different among the er sized particles. The LCS mobile bearing knees produced
groups and there was no patient selection bias for any patient smaller particulate debris (mean equivalent spherical diameter:
groups. Patient groups of 80 each included: 0.58 microm in LCS, 1.17 microm in PCA and 5.23 microm in
M/G) and more granular debris (mean value: 93% in LCS, 77%
Group I: all poly (AP), Group II: metal backed modular
in PCA and 15% in M/G).11
(MBM); Group III: RP-TKR (RP).
I (AP) II (MBM) III (RP)
TKR for Young, Active Patients
Lateral retinacular release (LLR) 3.8% 3.8% 3.8%
To date, the use of this implant has been reported only in rela-
Postop patellar tilt or 5.0% 7.0% 11%
tively elderly patients7,8,15,19,24
subluxation (PPT)
Knee ROM (degrees) • “a theoretical argument as there are no data in the literature
3 month 112 110 108 that support this concept. Most patients involved in these fol-
1 year 116 117 115 low-up studies are elderly individuals with low activity lev-
Stair climbing score els.”8
3 month 38 41 35
1 year 44 46 42 Tibio-Femoral Instability (A Problem Directly Attributable to
RP-TKR Design)
Conclusion: The RP TKR did not decrease the prevalence of LLR
There are a number of reports that describe early and late
or PPT and did not increase knee ROM or improve stair climb-
tibiofemoral instability related to the mobile bearings that
ing ability at 3 months or at 1 year postoperatively when com-
range from hemarthrosis, spin out, or frank dislocation. Early
pared with a posterior-stabilized, fixed-bearing knee.
postoperative dislocation has averaged 1.0% (r: 0.5-
Study 2: Patients undergoing bilateral TKR consented to accept 4.65%).4,5,10,12,22,25
random choice of knee (right or left).20 Outcomes included the
Knee Society Score (KSS), Oxford Knee Score (OKS), ROM and Early Instability
pain scores. One mobile-bearing prosthesis required early revi- Study 1. 31 consecutive pts with 50 deformed knees at 4.5 years
sion for dislocation of the meniscal component. At 1 yr the (range, 4-6 years). Complications included 2% dislocation, 4%
mean AKSS, OKS and pain scores for the new device were slight- anteroposterior instability, and 10% subluxation of the rotating
ly better (p < 0.025) than those for the fixed-bearing device. platform. The overall reoperation rate of 10% was significantly
There was no difference in ROM. higher than reported for the fixed bearing series. This prosthesis
is unsuitable for severely deformed knees.2

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
68 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 69

Study 2. One-surgeon series of 2485 patients. 10 patients with metal contact with polyethylene even with a mobile-bearing
rotating platform dislocation occurred within 2 years of TKR. 9 design.13
required open reduction. Increasing age, a preoperative valgus
deformity, and prior patellectomy were significantly associated Failure of Rotating Metal-Backed Patella 26
with rotating platform spinout.27
Peri-Prosthetic Stress Shielding 23
Late Instability
“The rotating platform design then is really just another knee
Study 1. 5 pts with late rotational dislocation of the rotating
design, clinically indistinguishable from many well-function-
platform bearing. The retrieved polyethylene bearings showed

SYMPOSIA AR KNEE
ing, fixed-bearing total knee designs.” 17
advanced wear and cold flow deformities and the poly thickness
was reduced. Progressive femorotibial ligament laxity and
reduction of the thickness of polyethylene with wearing break
down affected the originally well-balanced soft tissue tension of
the knee. The rotational degree of the rotating platform bearing
is unrestricted, which may result in late dislocation.
Polyethylene wear is unavoidable in knee prostheses using

REFERENCES 15. Jordan, L. R.; Olivo, J. L.; and Voorhorst, P. E.: Survivorship analysis of cementless
1. Barrack, R. L.; Nakamura, S. J.; Hopkins, S. G.; and Rosenzweig, S.: Winner of the meniscal bearing total knee arthroplasty. Clin Orthop Relat Res, (338): 119-23,
2003 James A. Rand Young Investigator's Award. Early failure of cementless 1997.
mobile-bearing total knee arthroplasty. J Arthroplasty, 19(7 Suppl 2): 101-6, 16. Kim, Y. H.; Kook, H. K.; and Kim, J. S.: Comparison of fixed-bearing and mobile-
2004. bearing total knee arthroplasties. Clin Orthop Relat Res, (392): 101-15, 2001.
2. Bhan, S., and Malhotra, R.: Results of rotating-platform, low-contact-stress knee 17. Pagnano, M. W., and Menghini, R. M.: Rotating platform knees: an emerging
prosthesis. J Arthroplasty, 18(8): 1016-22, 2003. clinical standard: in opposition. J Arthroplasty, 21(4 Suppl 1): 37-9, 2006.
3. Bhan, S.; Malhotra, R.; Kiran, E. K.; Shukla, S.; and Bijjawara, M.: A comparison 18. Pagnano, M. W.; Trousdale, R. T.; Stuart, M. J.; Hanssen, A. D.; and Jacofsky, D. J.:
of fixed-bearing and mobile-bearing total knee arthroplasty at a minimum fol- Rotating platform knees did not improve patellar tracking: a prospective, ran-
low-up of 4.5 years. J Bone Joint Surg Am, 87(10): 2290-6, 2005. domized study of 240 primary total knee arthroplasties. Clin Orthop Relat Res,
4. Buechel, F. F.: Recurrent LCS rotating platform dislocation in revision total knee (428): 221-7, 2004.
replacement: mechanism, management, and report of two cases. Orthopedics, 19. Papachristou, G.; Plessas, S.; Sourlas, J.; Chronopoulos, E.; Levidiotis, C.; and
26(6): 647-9, 2003. Pnevmaticos, S.: Cementless LCS rotating-platform knee arthroplasty in patients
5. Buechel, F. F., and Pappas, M. J.: Long-term survivorship analysis of cruciate-spar- over 60 years without patella replacement: a mid-term clinical-outcome study.
ing versus cruciate-sacrificing knee prostheses using meniscal bearings. Clin Med Sci Monit, 12(6): CR264-8, 2006.
Orthop Relat Res, (260): 162-9, 1990. 20. Price, A. J. et al.: A mobile-bearing total knee prosthesis compared with a fixed-
6. Buechel, F. F., and Pappas, M. J.: New Jersey low contact stress knee replacement bearing prosthesis. A multicentre single-blind randomised controlled trial. J Bone
system. Ten-year evaluation of meniscal bearings. Orthop Clin North Am, 20(2): Joint Surg Br, 85(1): 62-7, 2003.
147-77, 1989. 21. Ranawat, A. S.; Rossi, R.; Loreti, I.; Rasquinha, V. J.; Rodriguez, J. A.; and Ranawat,
7. Buechel, F. F., Sr.; Buechel, F. F., Jr.; Pappas, M. J.; and D'Alessio, J.: Twenty-year C. S.: Comparison of the PFC Sigma fixed-bearing and rotating-platform total
evaluation of meniscal bearing and rotating platform knee replacements. Clin knee arthroplasty in the same patient: short-term results. J Arthroplasty, 19(1):
Orthop Relat Res, (388): 41-50, 2001. 35-9, 2004.

8. Callaghan, J. J.; Squire, M. W.; Goetz, D. D.; Sullivan, P. M.; and Johnston, R. C.: 22. Ridgeway, S., and Moskal, J. T.: Early instability with mobile-bearing total knee
Cemented rotating-platform total knee replacement. A nine to twelve-year fol- arthroplasty: a series of 25 cases. J Arthroplasty, 19(6): 686-93, 2004.
low-up study. J Bone Joint Surg Am, 82(5): 705-11, 2000. 23. Sanchez-Sotelo, J.; Ordonez, J. M.; and Prats, S. B.: Results and complications of
9. Evans, M. C.; Parsons, E. M.; Scott, R. D.; Thornhill, T. S.; and Zurakowski, D.: the low contact stress knee prosthesis. J Arthroplasty, 14(7): 815-21, 1999.
Comparative Flexion After Rotating-Platform vs Fixed-Bearing Total Knee 24. Sansone, V., and da Gama Malcher, M.: Mobile-bearing total knee prosthesis: a 5-
Arthroplasty. J Arthroplasty, 21(7): 985-91, 2006. to 9-year follow-up of the first 110 consecutive arthroplasties. J Arthroplasty,
10. Fehring, T. K., and Valadie, A. L.: Knee instability after total knee arthroplasty. 19(6): 678-85, 2004.
Clin Orthop Relat Res, (299): 157-62, 1994. 25. Sorrells, R. B.: The rotating platform mobile bearing TKA. Orthopedics, 19(9):
11. Huang, C. H.; Ho, F. Y.; Ma, H. M.; Yang, C. T.; Liau, J. J.; Kao, H. C.; Young, T. 793-6, 1996.
H.; and Cheng, C. K.: Particle size and morphology of UHMWPE wear debris in 26. Tarkin, I. S.; Bridgeman, J. T.; Jardon, O. M.; and Garvin, K. L.: Successful biologic
failed total knee arthroplasties--a comparison between mobile bearing and fixed fixation with mobile-bearing total knee arthroplasty. J Arthroplasty, 20(4): 481-6,
bearing knees. J Orthop Res, 20(5): 1038-41, 2002. 2005.
12. Huang, C. H.; Ma, H. M.; Lee, Y. M.; and Ho, F. Y.: Long-term results of low con- 27. Thompson, N. W.; Wilson, D. S.; Cran, G. W.; Beverland, D. E.; and Stiehl, J. B.:
tact stress mobile-bearing total knee replacements. Clin Orthop Relat Res, (416): Dislocation of the rotating platform after low contact stress total knee arthroplas-
265-70, 2003. ty. Clin Orthop Relat Res, (425): 207-11, 2004.
13. Huang, C. H.; Ma, H. M.; Liau, J. J.; Ho, F. Y.; and Cheng, C. K.: Late dislocation 28. Woolson, S. T., and Northrop, G. D.: Mobile- vs. fixed-bearing total knee arthro-
of rotating platform in New Jersey Low-Contact Stress knee prosthesis. Clin plasty: a clinical and radiologic study. J Arthroplasty, 19(2): 135-40, 2004.
Orthop Relat Res, (405): 189-94, 2002.
14. Huang, C. H.; Ma, H. M.; Liau, J. J.; Ho, F. Y.; and Cheng, C. K.: Osteolysis in
failed total knee arthroplasty: a comparison of mobile-bearing and fixed-bearing
knees. J Bone Joint Surg Am, 84-A(12): 2224-9, 2002.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
69
SYM 07:Layout 1 1/12/07 11:39 AM Page 70

THE TIBIAL COMPONENT: MOBILE BEARING

John J. Callaghan, MD

I. TKA Design: Present Goals 2. Rollback PS rotating platform

A. Protect the Fixation Interface 3. Anterior translation CR TKA
1. Limit Prosthetic Loosening 4. Posterior rollback PS fixed bearing
B. Reduce Polyethylene Wear *5. No improvement in ROM with Mobile Bearing TKA
SYMPOSIA AR KNEE

1. Thicker polyethylene C. Wear Simulator

2. Improve modular locking mechanism 1. 94% decrease wear mobile vs. fixed
3. Return to monolithic components 2. Theory: decouple sagittal and rotational motion
4. Improved polyethylene sterilization D. Additional Kinematic Advantages of Mobile Bearings
*5. Increase conformity, decrease contact stress 1. Increase conformity without constraint
*6. Control sagittal and rotational kinematics independ- 2. Reduce PS post wear
ently 3. Improve patella tracking
4. Accommodate wide variations in axial rotation pat-
II. Clinical Results
terns
A. Excellent 15-Year Results with all Polyethylene
5. Decrease concern with tray rotational position
Components
6. Decrease fear of increase contact stress in high flex
B. Excellent 15-Year Results with Monolithic Metal Backed
knees
Components
C. Excellent 15-Year Results with Rotating Platform Mobile IV.Potential Disadvantage of Mobile Bearings
Bearing Components A. Instability: Minor Problem with PS
*D. Less Excellent Results with 1st Generation Modular B. Increase Backside Wear Especially if Third Body Present
Components C. Increase Cost
III. Kinematic and Biomechanical Analysis of Mobile Bearing V. Technical Considerations
vs. Fixed Bearing Designs A. Flexion Gap Symmetry
A. Contact Area Greater for Mobile Bearings (> 300 mm2 B. Extension Gap Symmetry
vs. < 250 mm2) than for Fixed Bearing C. Flexion-Extension Gap Equality
B. Fluoroscopic Data D. No Different than Fixed Bearing
1. No rollback LCS

REFERENCES: 5. Callaghan JJ, Squire MM, Goetz DD, Sullivan PM, Johnston RC: Cemented
1. Bartel DL, Bicknell VL, Ithaca MS, Wright TM: The effect of conformity, thickness rotating-platform total knee replacement: A 9 to 12 year follow-up study. J Bone
and material stresses in ultra-high molecular weight components for total joint Joint Surg, 82-A:705-711, 2000.
replacement. J Bone Joint Surg, 68-A:1041-1051, 1986. 6. Dennis DA, Komistek RD, Mahfouz MR, Walker SA, Tucker A: A multi-center
2. Bert JM: Dislocation/subluxation of meniscal bearing elements after New Jersey analysis of axial femorotibial rotation after total knee arthroplasty. Clin Orthop,
low-contact stress total knee arthroplasty. Clin Orthop, 254:211-215, 1990. 428:180-9, 2004.

3. Buechel FF Sr, Buechel FF Jr, Pappas MJ, D’Alessio J: Twenty-year evaluation of 7. McNulty PE, et al: In vitro wear rates of fixed mobile-bearing knees. ASTM sym-
meniscal bearing and rotating platform knee replacements. Clin Orthop, posium on crosslinked and thermally treated ultra-high molecular weight poly-
388:41-50, 2001. ethylene for total joint replacement. ASTM, November 2002.

4. Callaghan JJ, Insall JN, Greenwald AS, Dennis DA, Komistek RD, Murray DW, 8. Otto JK, Callaghan JJ, Brown TD. Mobility and contact mechanics of a rotating
Bourne RB, Rorabeck CH, Dorr LD: Mobile-bearing knee replacement: Concepts platform total knee arthroplasty. Clin Orthop, 392:24-37, 2001.
and results. Instr Course Lect. 50:431-49, 2001. Review PMID: 11372345 9. Steihl JB, Dennis DA, Komistek RD, Crane HS: In vivo determination of condy-
[PubMed – indexed for MEDLINE] lar lift-off and screw-home rotation in a mobile-bearing total knee arthroplasty. J
Arthroplasty, 14:293-299, 1999.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
70 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 71

CHEMICAL DVT PROPHYLAXIS AFTER DVT

Daniel J. Berry, MD

I. Introduction 3. Bleeding risk: Mechanical measures < Coumadin <

A. The topic of DVT prophylaxis has become controversial LMWH or Fondaparinux
and to some extent polarized. 4. All chemical prophylaxis measures are associated with
B. A persistent problem is the lack of studies that ask the some cost/inconvenience

SYMPOSIA AR KNEE
specific questions pertinent to orthopedic surgeons.
IV.Problems with Current Data
II. The Goals of Prophylaxis A. ACCP guidelines/pharmaceutical companies/FDA have
A. Prevent death due to pulmonary embolism. put excess priority on reducing DVT/PE (measured by
B. Prevent symptomatic DVT or PE which cause morbidity surrogate measures) and insufficient emphasis on mini-
C. Prevent symptomatic DVT/PE which require higher mizing bleeding risk.
intensity of anticoagulation (and hence increased bleed- B. We do not have good level one data comparing the
ing risk) modalities we would like to compare: i.e. mechanical
plus aspirin vs. Coumadin or LMWH or Fondaparinux
III. Chemical Prophylaxis
C. Most pharmaceutical studies were performed before
A. Pros
rapid mobilization protocols after TKA
1. Low rate of symptomatic PE/DVT
2. Lowest rate of asymptomatic DVT (how much does V. The Current Dilemma
this matter?) A. We would all like to use the simplest, cheapest method
3. Detailed meta-analysis, spearheaded by ACCP demon- with the lowest bleeding rate.
strates chemical prophylaxis provides lowest risk of B. None of us would be willing to accept a modality with a
VTE (using mostly surrogate measures of VTE) substantial clinical risk of death due to VTE to our
B. Cons patients.
1. There is no perfect chemical agent C. We don’t yet have good data to prove that ASA/mechani-
2. All chemical agents carry some risk of bleeding cal are as good as chemical measures.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
71
SYM 07:Layout 1 1/12/07 11:39 AM Page 72

MECHANICAL PROPHYLAXIS
Paul F. Lachiewicz, MD

DVT after TKA • Aspirin 325 mg the night prior to surgery and twice a day
• Different "disease" than after THA thereafter
• Most thrombi occur in calf only • Duplex scan post-op day #4
• Extension to proximal veins occurs infrequently • Only proximal thrombi treated with LMWH and warfarin
SYMPOSIA AR KNEE

• Pulmonary embolism very infrequent for 6 weeks

• Calf thrombi – scan repeated at 7-10 days
DVT after TKA
• Most thrombi occur in the first 24 hours post-op (Maynard Study Population
et al) • 423 patients, 472 knees
• Prophylaxis should be started pre-op or early post-op • No significant difference in gender, age, weight, diagnosis,
• Prophylaxis should not interfere with regional anesthesia or anesthesia
regional pain protocols
Results
• Prophylaxis should have low rate of bleeding
• Rapid inflation device Circumferential device
Goals VTED Prophylaxis TKA P.E. 0% P.E. 0.46%
Prevention of: DVT 6.9% DVT 15% (p = 0.007)
– Fatal pulmonary embolism • Unilateral 8.4% vs. 15.8% (p = 0.03)
– Symptomatic pulmonary embolism • Bilateral 4% vs. 15.9% (p = 0.05)
– Symptomatic deep vein thrombosis
Results
– Post-phlebitic syndrome
• Overall, low prevalence of death, symptomatic PE, DVT
Chemoprophylaxis TKA using aspirin and calf compression
• Risks of bleeding outweigh risks of DVT? • Lower prevalence of DVT with rapid-inflation calf compres-
• Hematomas ——> Infection? sion device
Decreased ROM? • Effective for unilateral and bilateral TKA
• How important is it to prevent asymptomatic, venogram
Other Studies Mechanical Prophylaxis
or Duplex scan-detected thrombi?
VenaFlow® plus Lovenox vs. VenaFlow® plus aspirin
Opinion: Aspirin alone is not recommended! Westrich et al J Arthroplasty 2006
• Haas et al JBJS 1990 • Prospective, randomized
Unilateral 47% DVT • 275 unilateral TKA patients
Bilateral 68% DVT • Duplex scan at 3-5 days and follow-up scan at 4-6 weeks
• Overall DVT 14.1% vs 17.8% (p = 0.27)
Mechanical Prophylaxis TKA
• No difference between groups!
• Important for patients with contraindications to, complica-
tions from pharmacologic agents Silbersack et al JBJS(B) 2004
• Wide variety of devices • Prospective, randomized
– Thigh-calf • Duplex scans
– Calf only • IPC device (VenaFlow®) applied post-op
– Foot pump • DVT 0% mech comp + LMWH
• Optimal characteristics for mechanical compression 40% LMWH!
devices?
Foot Pumps and Aspirin
• Prospective, randomized studies comparing efficacy of
Westrich et al JBJS(A) 1996
devices
• Foot pumps plus aspirin vs. aspirin alone
Mechanical Prophylaxis TKA • Prospective, randomized 164 TKAs
• Each device has its own mechanics with changes in peak • Mechanical plus aspirin 27% DVT
venous velocity and venous volume Aspirin alone 59% DVT (p < 0.001)
• Devices with rapid inflation produced the greatest increase • Combination more effective than aspirin; however, less
in peak venous velocity effective than calf compression
• Devices that compress calf and thigh produced the greatest
Efficacy of mechanical compression
increase in venous volume
• Decreased venous stasis
Hypothesis • Enhanced peak venous velocity
Pneumatic compression device that provides for a greater • Local effect on coagulation cascade
increase in peak venous velocity will have a lower prevalence • Combination of above
of thromboembolism
Conclusion
Two Mechanical Devices for Prophylaxis of • Mechanical prophylaxis and aspirin are safe, effective and
Thromboembolism after TKA acceptable for total knee patients
Lachiewicz et al JBJS (B) Nov 2004 • Now recommend rapid inflation, asymmetric calf compres-
sion device
Study Design
• Chemoprophylaxis for patients allergic to aspirin or with
• Prospective, randomized study by sealed envelopes
heritable coagulation disorders
• No exclusions – "high-risk" patients included
• Reasonable alternative to pharmacologic prophylaxis

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
72 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 73

REFERENCES 4. Maynard MJ, Sculco TP, Ghelman B. Progression and regression of deep vein
1. Grady-Benson JC, Oishi CS, Hanson PB, et al. Postoperative surveillance for thrombosis after total knee arthroplasty. Clin Orthop Relat Res.
deep vein thrombosis with duplex ultrasonography after total knee arthroplasty. J 1991;(273):125-30.
Bone Joint Surg 1994;76-A:1649. 5. Silbersack Y, Taute BM, Hein W, Podhaisky H. Prevention of deep vein thrombo-
2. Haas SB, Insall JN, Scuderi GR, Windsor RE, Ghelman B. Pneumatic sequential- sis after total hip and knee replacement. Low-molecular-weight heparin in com-
compression boots compared with aspiring prophylaxis of deep vein thrombosis bination with intermittent pneumatic compression. J Bone Joint Surg Br.
after total knee arthroplasty. J Bone Joint Surg Am. 1990;72(1):27-31. 2004;86(6):809-812.

3. Lachiewicz PF, Kelley SS, Haden LR. Two mechanical devices for prophylaxis of 6. Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB, Sculco TP. VenaFlow
thromboembolism after total knee arthroplasty. A prospective, randomised plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis

SYMPOSIA AR KNEE
study. J Bone Joint Surg Br. 2004;86-B(8):1137-1141. in total knee arthroplasty. J Arthroplasty 2006;21(6 Suppl 2):139-143.
7. Westrich GH, Sculco TP. Prophylaxis against deep vein thrombosis after total
knee arthroplasty. J Bone Joint Surg 1996;78-A:826.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
73
SYM 07:Layout 1 1/12/07 11:39 AM Page 74

GENDER SPECIFIC IMPLANTS: MARKETING HYPE OR

ANATOMIC FACT?”- PRO
Robert E. Booth, Jr., M.D.

Anthropologists, medical examiners, and observant surgeons components have required thicker tibial polyethylene implants,
SYMPOSIA AR KNEE

have long known that there are visible differences between male experienced an increase need for lateral releases and soft tissue
and female knees. While all tissues are involved, the salient adjustments, and have had lower Knee Society outcome scores
bony distinctions include a higher quadriceps angle, less abun- than their male counterparts. While the institution of better fit-
dant anterior femoral bone, and a higher AP/ML profile or ting parts for female knees has all the obvious logic of the hand-
“aspect ratio”. The last issue has been the driving force in ed components that preceded them a decade ago, the presump-
designing femoral components which do not require compro- tion that improved fit will result in improved function must be
mises in fitting the femoral component that would diminish proven. More sophisticated outcome instruments will be nec-
either the anterior bony integrity or the posterior femoral kine- essary to confirm this improvement. Nonetheless, the advent of
matics. Indeed, the ability to preserve the femoral “offset” or gender specific arthroplasties presages the racial and disease-
cam effect is crucial to obtaining good postoperative motion. based designs which will greatly enhance our current level of
There are strong data to suggest that women receiving standard sophistication in total knee arthroplasty.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
74 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 75

THE EFFECT OF GENDER ON OUTCOMES OF

TOTAL KNEE ARTHROPLASTY
Merrill A Ritter, MD

Background: The outcome of TKR is related to patient, surgeon, TKR, however was clinically equal for males and females for all

SYMPOSIA AR KNEE
and implant factors. The purpose of this study was to quantify the variables; however, improvements that are more significant
the effect of gender and implant sizing on the clinical outcome and beneficial were noted for females in pain and for males in
and survivorship of a TKR in a large series of knees with clinical stairs. There were no clinically significant differences found in
and radiographic follow-up. any postoperative variable related to femoral implant size
regardless of height. The survival for 10 and 15 years was 0.9922
Methods: 7326 primary AGC cruciated retaining total knee
and 0.9891 for males and 0.9895 and 0.9818 for females respec-
replacements. (Biomet, Warsaw, Indiana) ( range 2-17 years)
tively.
were performed from April 1987-May 2004 for the treatment of
osteoarthritis. Patients had a minimum 2-year follow-up. 40.5% Conclusions: We conclude that the outcome of TKR is a multi-
were male and 59.5% were female. We examined pre and post- factorial process and femoral implant size does not affect the
operative improvements in KSS, function scores, pain scores, clinical outcome when proper surgical technique is utilized. The
walking ability, stair climbing ability, flexion, and implant sur- female gender was associated with no clinically significant dif-
vivorship based on gender and implant sizing. For a given ferences in all variables except better improvement in pain and
femoral implant size, the clinical outcome associated with the poorer stair climbing ability compared to males. Importantly,
mean height was compared to two cohorts which were both no relationship between the size of the femoral component and
taller and shorter. Clinical outcomes were analyzed with Linear any clinical outcome could be determined with this large series
Regression and Wilcoxon thus examining a prosthesis which of TKR. Gender specific implants would appear to offer no clin-
overhangs or cuts into the bone. Failure rates were analyzed by ical advantage in this large series of TKR’s.
Kaplan Meier Analysis.
Level of Evidence: Prognostic study, Level III-2 (retrospective
Results: The female gender was associated with lower pre and cohort study)
postoperative scores (p<0.05). The improvement following

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
75
SYM 07:Layout 1 1/12/07 11:39 AM Page 76

NAVIGATION: READY FOR PRIME TIME

Aaron A. Hofmann, MD

Computer navigation has been introduced an as adjunct to total radiographic and clinical goal position (90 degrees to mechan-
knee arthroplasty (TKA) to assure precision positioning, accu- ical axis of femur) and 100% (50/50) of all tibial components
rate bone resection and optimal component alignment. It is were placed within +/- 3 degrees of 90 degrees for valgus knees
well accepted that alignment errors greater than three degrees and 92 degrees for varus knees relative to tibial anatomic axis.
SYMPOSIA AR KNEE

can be associated with poorer outcomes and more rapid failure. The data observed in the standard group dropped to 90%
A published retrospective study compared component align- (45/50) and 92% (46/50), respectively, when traditional instru-
ment between TKA’s performed using an imageless computer mentation without navigation was used. Tibio-femoral align-
navigation system and standard instrumentation by the same ment was also compared between the two groups. There were
surgeon. five outliers (45/50-90%) in the computer-assisted group and
seven outliers (43/50- 86%) in the standard group.
Fifty TKA’s were performed using the computer system and fifty
TKA’s using standard instrumentation. The computer system Computer assisted TKA reproducibly demonstrated improved
consisted of a workstation, an optical tracking system, and two accuracy compared to standard instrumentation. This system
custom instruments (universal positioning block, pointer). affords the surgeon the potential to eliminate or significantly
Tracking devices were attached to the femur and tibia. The cen- reduce outliers with regard to component position. In addition,
ter of the femoral head was computed based on a motion analy- violation of the intramedullary canal with associated fat emboli
sis of the femur. The computer system displayed traditional is avoided using this instrumentation. This improved accuracy
alignment axes. The bone cuts and component positioning may translate into improved component survivorship in the
were then performed using a computer assisted posterior refer- long term. Long-term studies will be needed to confirm that this
encing TKA system (Natural Knee™). improvement in accuracy correlates with improved function
and outcome.
When the navigation system was used 98% (49/50) of all
femoral components were placed within +/- 3 degrees of the

REFERENCES
1. Bolognesi M, Hofmann A. (2005). Computer Navigation versus Standard
Instrumentation for TKA: A Single-Surgeon Experience. Clin Orthop Relat Res,
440, 162-169.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
76 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 77

NAVIGATION: NOT READY FOR PRIME TIME – AGREE

John J. Callaghan, MD

I. Proponents of the use of CAOS in TKA would say: • Long learning curve with training of surgeons and other
• Its use increases both the precision and accuracy in team members
obtaining “optimal” knee alignment — Importance of anatomic landmark accuracy
• The real issue is: What are we really going to improve • Most “user friendly systems” require surgeon to register

SYMPOSIA AR KNEE
on? points by palpation (eg epicondyles)
• Even some experienced surgeons complain of difficulty
II. Our own published works contain tremendous outliers
palpating the landmarks
• Coronal Alignment
• Remember: “Garbage in = Garbage out”
— IB II at average 6.5 year f/u (JBJS 84-A, 2002)
• May increase accuracy???
• Femoral: average 95° (range 88 to 100°)
• Marriage of MIS and CAOS
• Tibial: average 88° (range 84 to 94°)
— Caveat of too much reliance on the computer
— PFC at average 10 year f/u (J Arthroplasty, 2000)
— Difficulty seeing with MIS, so tendency can be to rely
• FT angle: average 5° valgus (range 5° varus to 10° val-
on the computer for implant positioning, potentially
gus)
dangerous!!
— LCS Rotating Platform at min 15 year f/u (JBJS 87-A,
IV.Advice to patients regarding CAOS (if you aren’t an enthusi-
2005)
ast)
• FT angle: average 5° valgus (range 2° varus to 10° val-
• “Do you have GPS access in your car? If you know
gus)
where you are going, do you turn it on??” – James Bono,
— Revision Rates
MD
• 0% for all 3 studies above
• “CAOS?? I highly recommend it if your surgeon is: inex-
• Will be Difficult to show improvement in decreasing the
perienced, has poor hand-eye co-ordination, or has prob-
revision burden (a hard data point)
lems with depth perception.” – Richard Scott, MD
• Will be Really Difficult to show improvement in clinical
• “I’d rather use my on board computer!!!”
results (a soft multi-factorial data point)
V. Conclusion
III. Concerns with CAOS in TKA
• To have a successful TKA, need more than just “optimal”
• Takes longer
bony alignment
• Adds cost and complexity
— Need ligamentous balancing, flexion/extension gap
— From $100,000 to $300,000 start up and then there
checking, and “feel of the knee”
are software upgrades/updates
• If you are using CAOS, use it more as a check (eg
• Labor and equipment intensive
speedometer in a car)
— Computer malfunctions
— Be prepared to hit the manual over-ride button

REFERENCES: 2. Sikorski JM, Blythe MC. Learning the vagaries of computer-assisted total knee
1. Callaghan JJ, Liu SS, Warth LC. Computer-Assisted Surgery: A Wine Before its replacement. J Bone Joint Surg Br 2005;87:903.
Time. J Arthroplasty. 21(4 Suppl 1):27-28, 2006. 3. Stulberg SD. How accurate is current TKR instrumentation? Clin Orthop
2003;415:177.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
77
SYM 07:Layout 1 1/12/07 11:39 AM Page 78

LESS INVASIVE TKR

Alfred J. Tria, Jr., MD

Standard total knee arthroplasty has been in development since the varus and valgus alignment along with the correct slope for
the introduction of the first total knee in 1974.1,2 The tech- the tibial component. After the cut is completed, the bone can
niques of balancing the ligaments, equalizing the flexion-exten- be removed in one piece with the knee flexed about 80 degrees.
sion gaps, and adjusting the overall alignment have been per- A conventional femoral finishing block that has been down-
SYMPOSIA AR KNEE

fected so that the long term results are very satisfactory and are sized slightly is used to complete the femoral cuts. At this point,
now approaching 20 years for the follow up studies.3, 4, 5,6,7,8 the flexion and extension spaces can be compared and the bal-
Any significant change to the present successful techniques must ance of the knee checked. Releases for the varus knee can be per-
be approached with some trepidation. Minimally invasive sur- formed on the medial side of the tibia. Releases for the valgus
gery (MIS) for knee arthroplasty began in the late 1990’s. knee can be performed on the lateral side of the knee through
Repicci’s work with unicondylar knee replacement encouraged the standard medial arthrotomy. The exposure is not difficult for
further interest in both the limited surgical approach and in par- the releases because a total of approximately 20 mm of bone
tial knee arthroplasty.9,10 The logical extension of his work was has been removed from the distal femur and the proximal tibia
to apply the MIS principles to total knee surgery. Some investi- resulting in laxity and space. The tibial cut surface is now sized
gators implanted knee replacements using limited surgical for placement of the tray. The tibia can be subluxed forward
approaches over the past 15 years but no techniques have sur- with the knee flexed to about 80 degrees and a conventional
vived the test of time or replaced the standard surgery. With the tibia guide can be placed directly on the top of the cut surface.
now established MIS techniques for unicondylar surgery, MIS The trial tibial tray, femoral component, polyethylene insert,
total knee replacement has a much better foundation. and the patella are inserted in that order. After the patellar track-
ing, ligament balance, and range of motion are confirmed, the
Medial MIS Surgical Approach components are removed and the surfaces are prepared for
For the varus knee, a curvilinear medial incision is made from cementing. The MIS tibial tray has a shortened stem. The
the superior pole of the patella to the tibial joint line. The femoral component is cemented second and is inserted with the
arthrotomy is in line with the skin incision and can include a patella subluxed to the lateral side, but not everted. The patella
transverse incision in the capsule to improve visualization. In is cemented last. The polyethylene insert is a high flex design
the valgus knee, the incision can be made on the lateral side of and is locked into the tray after the cementing is completed.
the patella to the tibial joint line. The arthrotomy is performed Surgical drains are used for cell saver blood salvage. The arthro-
in a vertical fashion and the iliotibial band is peeled from the tomy is closed in the standard fashion along with the skin. The
tibial plateau joint line from anterior to posterior. The author patients begin full weight bearing ambulation and range of
does, however, prefer to perform all of the surgeries from the motion exercises within 2 to 4 hours after the surgery. No blood
medial approach. The knee is placed in extension and the pos- transfusions are required. Anticoagulation is started the day
terior surface of the patella is removed either with a guide or free after surgery and the patients are discharged from the hospital
hand. This step permits more laxity of the knee for the remain- on the second day after the operation.
der of the surgery by allowing greater space. The patella cannot
be everted for this step. An intramedullary femoral guide is used Results
that references the medial femoral condyle and Whiteside’s line. The author has reported the 2 to 4 year results showing more
The anterior and distal femoral cuts are then completed using rapid recovery, less pain, and increased range of motion.11 The
slotted cutting guides. The tibial guide is an extramedullary ref- procedure does require more operative time and is not as accu-
erencing instrument that is attached to the lower leg with an rate as the standard TKA but these findings did not result in any
ankle clamp and tibial tubercle pins. It must be set properly for clinical failures.

REFERENCES 7. Scott RD, Volatile TB. 12 years experience with posterior cruciate retaining total
1. Insall J, Ranawat C, Scott WN, Walker P. Total condylar knee replacement. knee arthroplasty. Clin Orthop 205: 100-107, 1986.
Preliminary report. Clin Orthop 120: 149-154, 1976. 8. Ritter MA, Herbst SA, Keating EM, Faris PM, Meding JB. Long term survivorship
2. Insall J, Tria A, Scott W. The total condylar knee prosthesis. The first five years. analysis of a posterior cruciate retaining total condylar total knee arthroplasty.
Clin Orthop 145: 68-77, 1979. Clin Orthop 309:136-145, 1994.

3. Ranawat C, Flynn W, Saddler S, Hansraj K, Maynard M. Long-term results of the 9. Repicci JA, Eberle RW. Minimally invasive surgical technique for unicondylar
total condylar knee arthroplasty. A 15-year survivorship study. Clin knee arthroplasty. Journal of the Southern Orthopaedic Association 8(1): 20-27,
Orthop286:96-102, 1993. 1999.

4. Stern S, Insall J, Posterior stabilized prosthesis. Results after follow-up of nine to 10. Romanowski MR and Repicci JA. Minimally invasive unicondylar arthroplasty:
twelve years. JBJS 74: 980-986, 1992. Eight-year follow-up. Journal of Knee Surgery 15(1):17-22, 2002.

5. Colizza W, Insall J, Scuderi G. The posterior stabilized total knee prosthesis: 11. Chen AF, Alan RK, Redziniak DE, and Tria AJ. Quadriceps sparing total knee
assessment of polyethylene damage and osteolysis after a ten year minimum fol- arthroplasty: Initial experience with two to four year results, JBJS (Br) 88:1448-
low-up. JBJS 77: 1716-1720, 1995. 53, 2006.

6. Malkani A, Rand J, Bryan R, Wallrich S. Total knee arthroplasty with the kinemat-
ic condylar prosthesis. A ten year follow-up study. JBJS 77:423-431, 1995.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
78 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 79

WHY I USE A MORE TRADITIONAL TKR APPROACH

Arlen D. Hanssen, MD

1) Traditional TKR • Some advocates clearly indicate this patient selection bias
One of the most successful surgical procedures ever developed. by stating
Since introduction, this procedure and the implants have con- — “The patient’s ideal weight is < 180 lbs. However, the true
tinued to evolve and improve so that excellent clinical out- limitation is the circumference of the knee with respect

SYMPOSIA AR KNEE
comes, minimal complications, and long-term durability are to the length of the leg”30
expectations of the patient and surgeon. — “the ideal patient for a MIS TKR and limited arthrotomy
seems to be a thin woman with a low body mass index,
2) What is MIS TKR?20 a narrow femur, and good preop ROM.”28
Currently an evolving area of investigation that includes multi- B) Scientific Data
ple surgical approaches with no established definitions, and • Most studies compare the results of MIS TKR with his-
lacks comparative scientific data regarding patient outcomes, torical controls8,11
complications, or implant durability. MIS TKR appears to • Quantification of soft-tissue damage is currently not
require careful patient selection criteria and is currently tar- codified
nished by its close association with patient marketing efforts.17 • Length of incision and capsulotomy only recently
documented in literature
A) No commonly accepted definition of MIS TKR
• Recent investigation comparing MIS TKR approaches
Less-invasive: most surgeons do as a process of proce-
revealed no differences1
dural evolution
Prospective randomized double-blind study com-
Small-incision: this occurred over the past several
paring mini-subvastus and "quadriceps-sparing"
decades
approach. All PS implants identical, performed by
Minimally invasive: is concept really possible with joint
the same surgeon with the same set of downsized
replacement?
instruments. Anesthesia, postoperative analgesia,
Current suggestions / criteria include: and rehabilitation protocol was same in all
Incision is ½ length of traditional incision patients. There was no difference in any of the
Smaller capsular incision studied variables between the mini-subvastus and
No violation of extensor mechanism or suprapatellar "quadriceps-sparing" approach in relation to short
pouch term recovery or early results.
No quadriceps eversion • Healthy skepticism is appropriate until long-term data
No tibiofemoral dislocation6 has been reported.2
B) Proposed Advantages of MIS TKR C) Additional Confounding Variables
decreased postop pain, decreased blood loss, decreased • Many institutions have unique perioperative multi-
muscle damage, shortened hospital stay and rehab, modal anesthesia and rehabilitation protocols specifi-
decreased scarring, improved cosmesis, and higher cally designed for MIS TKR patients4
patient satisfaction • Multimodal anesthesia pathways appear to provide
C) There are a large variety of proposed surgical techniques: the majority of benefit for the patient in the postoper-
This creates significant difficulty when attempting to ative time period for both traditional and MIS
compare and analyze the effects of MIS as separated approaches13,14
from the differences in approaches whether using MIS or
4) Disadvantages of MIS TKR
traditional
• Decreased field of vision for vital structures and normal
MIS Mini-Subvastus21,25
anatomic landmarks
MIS Mini-Midvastus12,18
• Potential for higher complication rate (particularly dur-
MIS Mini-Medial Parapatellar23,24
ing learning curve)26
MIS Quadriceps Sparing3,29
— Wound healing / skin necrosis
3) Problems with Assessment of MIS TKR — Inadvertant injury to liagamentous16 and neurovascu-
A) Patient Selection Criteria lar structures
Suggested MIS patient selection variables:24 — Component malposition9,10
• Size of femur • Longer duration of operative procedure5,30
• Length of patellar tendon • Higher expense related to instrumentation and procedur-
• Body habitus al duration7
• Minimal fixed angular deformity (< 10 varus, < 15 • Potential for decreased durability of implants compared
flexion) with traditional TKR
• >90 degree arc of preop ROM • Only applicable in a small subset of selected patients16
• It is unquestionable that careful patient selection crite-
ria bias the reported results of MIS TKR18,27

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
79
SYM 07:Layout 1 1/12/07 11:39 AM Page 80

Conclusion aspects of the procedure with regards to complications, func-

The only way to assess the efficacy of MIS TKR techniques as tional outcomes, patient satisfaction and long-term implant
compared with so-called traditional approaches will be to do a durability.6,19,22
prospective randomized clinical trial that includes the same
"Although these procedures have generated incredible interest
patient selection criteria, same perioperative multimodal anes-
and enthusiasm, I am concerned that they may be performed to
thesia and rehabilitation protocols, and accurately assess all
the detriment of our patients."15
SYMPOSIA AR KNEE

REFERENCES 15. Hungerford, D. S.: Minimally invasive total hip arthroplasty: in opposition. J
1. Aglietti, P.; Baldini, A.; and Sensi, L.: "Quadriceps-Sparing" versus Mini-Subvastus Arthroplasty, 19(4 Suppl 1): 81-2, 2004.
Approach in Total Knee Arthroplasty. Clin Orthop Relat Res, 2006. 16. Kim, Y. H.; Sohn, K. S.; and Kim, J. S.: Short-term results of primary total knee
2. Alan, R. K., and Tria, A. J., Jr.: Quadriceps-sparing total knee arthroplasty using arthroplasties performed with a mini-incision or a standard incision. J
the posterior stabilized TKA design. J Knee Surg, 19(1): 71-6, 2006. Arthroplasty, 21(5): 712-8, 2006.

3. Berger, R. A.; Deirmengian, C. A.; Della Valle, C. J.; Paprosky, W. G.; Jacobs, J. J.; 17. Labovitch, R. S.; Bozic, K. J.; and Hansen, E.: An evaluation of information avail-
and Rosenberg, A. G.: A technique for minimally invasive, quadriceps-sparing able on the internet regarding minimally invasive hip arthroplasty. J Arthroplasty,
total knee arthroplasty. J Knee Surg, 19(1): 63-70, 2006. 21(1): 1-5, 2006.

4. Berger, R. A.; Sanders, S.; D'Ambrogio, E.; Buchheit, K.; Deirmengian, C.; 18. Laskin, R. S.: Minimally invasive total knee replacement using a mini-mid vastus
Paprosky, W.; Della Valle, C. J.; and Rosenberg, A. G.: Minimally invasive quadri- incision technique and results. Surg Technol Int, 13: 231-8, 2004.
ceps-sparing TKA: results of a comprehensive pathway for outpatient TKA. J Knee 19. Lonner, J. H.: Minimally invasive approaches to total knee arthroplasty: results.
Surg, 19(2): 145-8, 2006. Am J Orthop, 35(7 Suppl): 27-9, 2006.
5. Bonutti, P. M.; Mont, M. A.; and Kester, M. A.: Minimally invasive total knee 20. McGrory, B.; Callaghan, J.; Kraay, M.; Jacobs, J.; Robb, W.; Wasielewski, R.; and
arthroplasty: a 10-feature evolutionary approach. Orthop Clin North Am, 35(2): Brand, R. A.: Editorial: minimally invasive and small-incision joint replacement
217-26, 2004. surgery: what surgeons should consider. Clin Orthop Relat Res, 440: 251-4, 2005.
6. Bonutti, P. M.; Mont, M. A.; McMahon, M.; Ragland, P. S.; and Kester, M.: 21. Pagnano, M. W., and Meneghini, R. M.: Minimally invasive total knee arthroplas-
Minimally invasive total knee arthroplasty. J Bone Joint Surg Am, 86-A Suppl 2: ty with an optimized subvastus approach. J Arthroplasty, 21(4 Suppl 1): 22-6,
26-32, 2004. 2006.
7. Bozic, K. J., and Hansen, E.: The economics of minimally invasive total knee 22. Reid, J. B., 3rd; Guttmann, D.; Ayala, M.; and Lubowitz, J. H.: Minimally invasive
arthroplasty. J Knee Surg, 19(2): 149-52, 2006. surgery-total knee arthroplasty. Arthroscopy, 20(8): 884-9, 2004.
8. Cook, J. L.; Scuderi, G. R.; and Tenholder, M.: Incidence of Lateral Release in 23. Scuderi, G. R.: Minimally invasive total knee Arthroplasty: surgical technique. Am
Total Knee Arthroplasty in Standard and Mini-Incision Approaches. Clin Orthop J Orthop, 35(7 Suppl): 7-11, 2006.
Relat Res, 2006. 24. Scuderi, G. R.; Tenholder, M.; and Capeci, C.: Surgical approaches in mini-inci-
9. Dalury, D. F., and Dennis, D. A.: Mini-incision total knee arthroplasty can sion total knee arthroplasty. Clin Orthop Relat Res, (428): 61-7, 2004.
increase risk of component malalignment. Clin Orthop Relat Res, 440: 77-81, 25. Sporer, S. M.: The minimally invasive subvastus approach for primary total knee
2005. arthroplasty. J Knee Surg, 19(1): 58-62, 2006.
10. Fisher, D. A.; Watts, M.; and Davis, K. E.: Implant position in knee surgery: a 26. Stulberg, S. D.: Minimally invasive navigated knee surgery: an American perspec-
comparison of minimally invasive, open unicompartmental, and total knee tive. Orthopedics, 28(10 Suppl): s1241-6, 2005.
arthroplasty. J Arthroplasty, 18(7 Suppl 1): 2-8, 2003.
27. Tanavalee, A.; Thiengwittayaporn, S.; and Itiravivong, P.: Results of the 136 con-
11. Haas, S. B.; Cook, S.; and Beksac, B.: Minimally invasive total knee replacement secutive minimally invasive total knee arthroplasties. J Med Assoc Thai, 88 Suppl
through a mini midvastus approach: a comparative study. Clin Orthop Relat Res, 4: S74-8, 2005.
(428): 68-73, 2004.
28. Tenholder, M.; Clarke, H. D.; and Scuderi, G. R.: Minimal-incision total knee
12. Haas, S. B.; Manitta, M. A.; and Burdick, P.: Minimally Invasive Total Knee arthroplasty: the early clinical experience. Clin Orthop Relat Res, 440: 67-76,
Arthroplasty: The Mini Midvastus Approach. Clin Orthop Relat Res, 2006. 2005.
13. Hebl, J. R.; Kopp, S. L.; Ali, M. H.; Horlocker, T. T.; Dilger, J. A.; Lennon, R. L.; 29. Tria, A. J., Jr.: Exploring the depths of minimally invasive quadriceps-sparing total
Williams, B. A.; Hanssen, A. D.; and Pagnano, M. W.: A comprehensive anesthe- knee arthroplasty. Orthopedics, 29(3): 214-5, 2006.
sia protocol that emphasizes peripheral nerve blockade for total knee and total
hip arthroplasty. J Bone Joint Surg Am, 87 Suppl 2: 63-70, 2005. 30. Tria, A. J., Jr., and Coon, T. M.: Minimal incision total knee arthroplasty: early
experience. Clin Orthop Relat Res, (416): 185-90, 2003.
14. Horlocker, T. T.; Kopp, S. L.; Pagnano, M. W.; and Hebl, J. R.: Analgesia for total
hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve
block. J Am Acad Orthop Surg, 14(3): 126-35, 2006.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
80 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 81

CONTROLLING PAIN AFTER TOTAL HIP AND KNEE

REPLACEMENT USING A MULTIMODAL PROTOCOL WITH
LOCAL PERIARTICULAR INJECTIONS: A PROSPECTIVE,
RANDOMIZED STUDY

SYMPOSIA AR KNEE
CS Ranawat, MD

Introduction: Pain, recovery of functional milestones, and overall satisfaction

The purpose of this study is to describe a multimodal pain pro- were assessed.
tocol including a novel periarticular injection and to evaluate its
effects on pain control, narcotic consumption, and recovery of Results:
function after total joint replacement. Patients in the hip injection group demonstrated significantly
lower average pain scores (3.8 vs 5.77 on POD # 1; p=0.0067).
Methods: Narcotic use and associated side effects were significantly lower
An IRB-approved prospective randomized study was conducted and straight leg raise and overall satisfaction were significantly
to compare different perioperative pain management protocols. higher (52% vs 15% and 9.2/10 vs 6.7/10 respectively).
For THR, patients were randomized to either the PCA or the
Average pain scores and overall patient satisfaction were com-
periarticular injection group and for TKR, patients were ran-
parable between the knee injection group and the PCA + FNB
domized to the PCA plus femoral nerve block (FNB) or the peri-
group. However, the injection group demonstrated lower nar-
articular injection group.
cotic usage and side effects and increased ability to straight leg
105 patients (56 hips and 49 knees) were enrolled. All patients raise (63% vs 21%).
received a comprehensive protocol including perioperative
analgesics, anti-inflammatories, patient education, and Discussion and Conclusion:
advanced rehabilitation. Periarticular injection with a multimodal protocol was shown
to decrease pain and improve functional recovery compared to
The injection consists of a local proprietary mixture of five med-
conventional pain control modalities.
ications with different mechanisms of action.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
81
SYM 07:Layout 1 1/12/07 11:39 AM Page 82

WHAT TO DO WHEN TOTAL KNEE

ARTHROPLASTIES FAIL?
SYMPOSIA AR KNEE

CHALLENGES AND CONTROVERSIES (BB)

Moderator: Michael A. Mont, MD, Baltimore, MD
(a - TissueLink, Ossacur, e - Stryker Orthopaedics, Wright Medical Technology)
As the number of primary total knee arthroplasties in the United States increase, the
number of complications and revision knee arthroplasties continues to increase as well. This
symposium will outline an algorithm for the diagnosis and management of failed total
knee arthroplasties.

I. Introduction, Epidemiology and Reasons for Revision

Michael A. Mont, MD, Baltimore, MD (a – TissueLink, Ossacur, e - Stryker
Orthopaedics, Wright Medical Technology)

II. Infection Issues

a. Ruling Out and Dealing with Infection
Robert L. Barrack, MD, Saint Louis, MO (c – Smith & Nephew)
b. Debate: Infection – Articulating Spacer
Robert L. Barrack, MD, Saint Louis, MO (c – Smith & Nephew)
c. Debate: Non-Articulating Spacer
Michael A. Mont, MD, Baltimore, MD (a – TissueLink, Ossacur, e - Stryker
Orthopaedics, Wright Medical Technology)

III. Exposures
a. Exposures
Robert Booth, MD, Philadelphia, PA (c – Zimmer)
b. Debate: Quadriceps Snip
Chitranjan S. Ranawat, MD New York, NY (a – Stryker Howmedica, a, c – DePuy)
c. Debate: Tibial Tubercle Osteotomy
Robert Booth, MD, Philadelphia, PA (c – Zimmer)

IV. Knee Instability

a. Debate: Flexion Gap Balancing
Michael A. Mont, MD, Baltimore, MD (a – TissueLink, Ossacur, e - Stryker
Orthopaedics, Wright Medical Technology)
b. Debate: Extension Gap Balancing
Chitranjan S. Ranawat, MD, New York, NY (a – Stryker Howmedica, a, c – DePuy)

V. Operative/Bone Loss Considerations

a. Use of Allografts
Gerard A. Engh, MD Alexandria, VA (a – Inova Health Care Services, c - DePuy,
Smith Nephew, e - Alexandria Research Technologies, LLC
b. Using Stems, IM Rods, Wedges, Spacers
Robert L. Barrack, MD, Saint Louis, MO (c – Smith & Nephew)
c. Debate: Not Cementing the Stem
Gerard A. Engh, MD Alexandria, VA (a – Inova Health Care Services, c - DePuy,
Smith Nephew, e - Alexandria Research Technologies, LLC
d. Debate: Cementing the Stem
Robert L. Barrack, MD, Saint Louis, MO (c – Smith & Nephew)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
82 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:39 AM Page 83

VI. Managing Ligamentous Instability in Revision Total Knee Arthroplasty

Robert L. Barrack, MD, Saint Louis, MO (c – Smith & Nephew)
a. Debate: What Inserts I Use For Revision

SYMPOSIA AR KNEE
Kenneth A. Krackow, MD, Buffalo, NY (a, c, e – Stryker Howmedica)
b. Debate: Contrained Inserts
Chitranjan S. Ranawat, MD, New York, NY (a – Stryker Howmedica, a,c - DePuy)

VII. Alignment
a. Alignment in Total Knee Revision
Kenneth A. Krackow, MD, Buffalo, NY (a, c, e – Stryker Howmedica)
b. Debate: Computer-Assisted Surgery for Revision/Helpful
Kenneth A. Krackow, MD, Buffalo, NY (a, c, e – Stryker Howmedica)
c. Debate: Computer-Assisted Surgery for Revision/Not Necessary
Robert E.Booth, Jr., MD, Philadelphia, PA (c – Zimmer)

VIII. Important Topics

a. Extensor Mechanism Repairs Post- Patellectomy/Reconstructions of Patella
Robert E. Booth, Jr., MD, Philadelphia, PA (c – Zimmer)
b. Anesthesia Considerations for Revision Knee/Pain Control
Chitranjan S. Ranawat, MD, New York, NY (a – Stryker Howmedica, a, c – DePuy)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
83
SYM 07:Layout 1 1/12/07 11:39 AM Page 84

WHAT TO DO WHEN TOTAL KNEE ARTHROPLASTIES FAIL?

CHALLENGES AND CONTROVERSIES
1. Introduction The most common method remains a two stage system of
A. Introduction: The purpose of this symposium is to review removal of the prosthesis and reimplantation at a later date after
the current modes of failure in total knee arthroplasty. There are the infection has been eradicated. It remains controversial on
SYMPOSIA AR KNEE

various reasons for failure such as patient activity, increased how long to wait and what methods are used to insure that
polyethylene wear, aseptic loosening, infection, instability, there is no persistent infection. A large debate concerns whether
arthrofibrosis, malalignment, and malposition. This sympo- to use a spacer prosthesis or antibiotic-impregnated spacers.
sium will also address techniques to avoid surgical mistakes and Recently, articulating spacers have been used to try to maintain
outline various options for the management of failed total knee motion, but this technique is controversial and is a subject of
arthroplasties. debate.
B. Epidemiology: The number of total knee replacements con-
3. Exposures
tinues to increase. In various studies, anywhere from ten to
The standard gold standard exposure is a medial parapatellar
twenty-five percent of knees will require a revision within ten
arthrotomy. Most surgeons will continue to use this technique
years of time. Recent reports from the Swedish registry show
and will evert the patella. Recently, there have been some stud-
approximately a ten percent revision rate at ten years. This
ies that have shown that not everting the patella may be helpful
means that this problem will continue to increase and the
and less invasive approaches have been used even for minimal-
arthroplasty surgeon will have to be aware of the issues in this
ly invasive revision total knee arthroplasty. There are various
symposium.
ancillary techniques that allow for greater exposure to insure the
C. Reasons for Revision: In a recent Knee Society award-win- ability to visualize all structures and perform a revision. When
ning paper, Sharkey et al. described the reasons for total knee one is dealing with a very tight knee, it is still controversial
revision. Close to fifty percent of patients came to a revision whether one should use a quadricepsplasty from above or per-
within two years of index total knee arthroplasty for reasons form a tibial tubercle osteotomy from below, which is a subject
such as instability, patellar maltracking, and severe malalign- of debate.
ment. In summary, many of the reasons for revisions have to do
with the technique of surgical implantation. Problems with 4. Knee Balancing
long-term wear of polyethylene or osteolysis occur many years There is some controversy of how to perform gap balancing
later. Infections after total knee replacements range from one to when doing a total knee revision. When using flexion gap bal-
ten percent and remain a very large part of the revision popula- ancing, principles advocated balancing in flexion so that nine
tion which leads to tremendous morbidity and costs. possibilities have been reduced to three (just right, too tight, or
too loose). Dealing with knees that are too loose requires then
2. Infection Issues simply advancing the femur which can be done with modern-
It is sometimes very difficult to diagnose a deep knee infection. day revision prostheses. Dealing with an extension gap that is
There are a host of clinical, laboratory, and special tests that are too tight requires resecting more bone for which the limits are
used to diagnose infection. It has been previously believed that the origins of the collateral ligaments. Despite this apparent use
certain tests have been considered gold standards for diagnosing of balancing total knee revisions in flexion, there are some
infection, but at this point in time, there is no single test that can advocates for extension gap balancing which will be discussed
absolutely make the diagnosis. Important clinical findings are and contrasted with flexion gap balancing.
swelling, erythema, and pain. For knee replacements, joint aspi-
rations can be very useful and typically surgeons will look for 5. Operative/Bone Loss Considerations
high white blood cell counts (greater than 30,000 cells per mil- I. Dealing With Bone Loss in Revision TKA
limeter3). Recent data suggests that high polymorphonuclear Problem: Bone loss with failed TKA compromises the
leukocyte counts are just as important (greater than 80% fixation stability of new implants
PMNs). Gram stains have been noted in recent papers to be of Goal: To achieve optimal implant stability and ligament
limited utility. Although standard radiographs are always balance
important, they are rarely diagnostic for an infection. Special • Preserve strong viable metaphyseal host bone
nuclear medicine tests such as bone scans, gallium scans, and • Reconstruct bone defects
indium scans generally have low specificity for infection. • Restore anatomic joint line
In dealing with deep infections, traditional methods of treat- Anderson Orthopaedic Research Institute Bone Defect
ment have prompted removal of prostheses in preparation for a Classification
second stage reimplantation procedure. There is some contro- • Type 1 (Femur or Tibia)
versy with this concerning timing of removal and treatment, as — Minor bone defects in the metaphyseal bone
some authors have advocated debridements at early time inter- — Does not require a revision component
vals to try to save prostheses that were previously well-function- — A normal joint line level with a full metaphyseal seg-
ing. Other authors have taken a quite opposite approach by ment
advocating removal of components, cleaning, and during the • Type 2 (Femur or Tibia)
same setting reimplanting a new prosthesis in a one-stage man- — Damaged metaphyseal segment
ner. — Requires large area of cement fill, augments, or bone
graft to restore a reasonable joint line level

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
84 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 85

— Requires a stemmed revision component press fit. Surgeons that support the use of press-fit stems favor
• Type 3 (Femur or Tibia) cementing the base of the stem in the metaphyseal segment. The
— Deficient metaphyseal segment advantages to the use of a cementless stem are that they inte-
— Bone loss that compromises a major portion of the grate with the intramedullary instruments of most revision knee
condyle or plateau systems, they guarantee axial alignment, they are easy to remove,
— Loss of the metaphyseal fullness on preoperative radi- and they allow axial loads to stimulate bone healing when
ographs structural allografts are used. The advantages to a fully cement-
— Requires allografts, large augments or custom compo- ed stem are that they extend the fixation interface, provide lati-
nents tude in component orientation, and have proven successful at

SYMPOSIA AR KNEE
— Stemmed components required intermediate follow-up intervals. The stability of a 75-mm fully
cemented stem is equivalent to the stability provided by a 150-
Bone Deficiency in Revision Surgery (Deep and irregular
mm press fit stem with an adequate diameter to achieve
shaped defects)
endosteal fit.
• SURGICAL OPTIONS CONCERNS
Modular implants size limitation and cost Regardless of the method of fixation selected for the revision,
Custom implants cost and time delay the surgical technique for managing the damaged metaphyseal
Bone graft durability bone is the same. The damaged metaphyseal bone must be
cleared of fibrous tissue and dead bone to provide an interface
Management Options
that will allow cement interdigitation. A cancellous structure
• Methylmethacrylate or reinforced methylmethacrylate
that will accept cement penetration is essential. Whenever there
with cancellous bone screws
is satisfactory cancellous bone in the metaphyseal segment,
• Bone Graft:
excellent results can be achieved with either cemented or press-
Advantages — No additional implant cost
fit stems. When using fully cemented stems, the stem should be
— Bone shaped to the defect
oriented so as to reduce stress on damaged ligaments, a cement
— Incorporation and remodeling with
restrictor should be inserted, and the cement should be pressur-
host bone
ized as much as possible. A fluted stem should not be used with
— Bone stock restoration if revision neces-
cement fixation.
sary
Disadvantages — Possible disease transmission with allo- Uncemented stems are favorable in certain situations. The use of
grafts uncemented stems is preferable in revisions for infection, for
— Questioned long term durability treating periprosthetic fractures, and when using structural allo-
grafts with the revision arthroplasty. Cemented stems are prefer-
The Interface Problem
able in revisions that require altered knee alignment to protect
• Viable cancellous bone is essential for cement bonding and
damaged soft tissues and in cases managed with impaction
bone graft union
bone grafting.
Solution: resect or ream defect to viable cancellous bone
• Stabilize the graft Despite some surgeons using allografts, most revision knee
— Cement fixation: rigidly stabilizes the graft to the com- arthroplasties have the expansive use of various stems, wedges,
ponent and spacers to make up for bone loss. These methods will be
— Cementless fixation: minimal initial graft stability - contrasted with the use of allografts.
adjunct fixation
Traditionally, many surgeons cemented the entire stem to gain
• Always use a stemmed implant with bone grafts
stability with total knee arthroplasty. Recently, there are many
Techniques of Bone Grafting in Revision TKA advocates for not cementing the entire stem, but just cementing
• Use structural allografts for large defects the distal component. This topic will be debated.
— Femoral head: for partial loss of condyle or plateau
— Distal femur or proximal tibia: for complete loss of 6. Inserts and Stability
condyle or plateau There are various non-constrained to semi-constrained inserts
• Interface preparation: achieve interference fit for the allo- that can be used for revision arthroplasty. Typically, a higher
graft degree of constraint is needed because of potential ligamentous
• Stemmed component - canal filling stem imbalance. A discussion of different inserts used for revision
• Step cut allograft for rotational orientation will be presented with a debate of when to use constrained
• Cement the component but not the stem inserts.
II. Stems in Revision TKA In some cases, even using various constrained prostheses will
The necessity for using stems in revision TKA is predicated on not make up for ligamentous balance. At present, there are few
the frequency of bone defects and the reduction in strength of surgeons that are reconstructing ligaments or using allografts for
metaphyseal bone encountered with this type of surgery. Over a ligamentous reconstruction. In many of these cases of severe
five-year year period at the Anderson Clinic, Type 2 and Type 3 bone loss or ligamentous loss, rotating hinges can still be used.
bone defects were encountered in more than 50% of revision The role of rotating hinges will be described.
knee cases. The efficacy for stems is documented in an outcome
study that reported a 26% re-revision rate for revision TKA cases 7. Alignment
treated with implants with short stems, a 14% re-revision rate Because of bone loss or previously malaligned knees, it can
for implants managed with intermediate length stems, and a often be very difficult to regain the appropriate alignment in
6% re-revision rate for revision knees managed with long mod- knee revisions. The surgical techniques for obtaining the appro-
ular stems. priate ligamentous balance and alignment will be described.
Recently, there have been advances in computer-assisted surgery
An on-going controversy is centered on whether or not the
that may help establish alignment of the knees. It is still debat-
stems used with revision implants should be fully cemented or
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
85
SYM 07:Layout 1 1/12/07 11:40 AM Page 86

able whether this expensive new technology is helpful in the including perioperative analgesics, anti-inflammatories, patient
revision situation. This topic will be debated. education, and advanced rehabilitation. The injection consists
of a local proprietary mixture of five medications with different
8. Important Topics mechanisms of action.
There are a number of problems with the extensor mechanism
Pain, recovery of functional milestones, and overall satisfaction
that need to be addressed in revision arthroplasty. Certain
were assessed.
patients need revisions after their patella has been resected or
there is minimal fragment of patella left. There are various
Results:
reconstructions to the patella that have been advocated and
SYMPOSIA AR KNEE

Patients in the hip injection group demonstrated significantly

these will be described.
lower average pain scores (3.8 vs 5.77 on POD # 1; p=0.0067).
Narcotic use and associated side effects were significantly lower
Introduction:
and straight leg raise and overall satisfaction were significantly
The purpose of this study is to describe a multimodal pain pro-
higher (52% vs 15% and 9.2/10 vs 6.7/10 respectively).
tocol including a novel periarticular injection and to evaluate its
effects on pain control, narcotic consumption, and recovery of Average pain scores and overall patient satisfaction were com-
function after total joint replacement. parable between the knee injection group and the PCA + FNB
group. However, the injection group demonstrated lower nar-
Methods: cotic usage and side effects and increased ability to straight leg
An IRB-approved prospective randomized study was conducted raise (63% vs 21%).
to compare different perioperative pain management protocols.
For THR, patients were randomized to either the PCA or the Discussion and Conclusion:
periarticular injection group and for TKR, patients were ran- Periarticular injection with a multimodal protocol was shown
domized to the PCA plus femoral nerve block (FNB) or the peri- to decrease pain and improve functional recovery compared to
articular injection group. 105 patients (56 hips and 49 knees) conventional pain control modalities.
were enrolled. All patients received a comprehensive protocol

REFERENCES 15. Jones RE. Mobile bearings in revision total knee arthroplasty. Instr Course Lect.
1. Barrack RL. Specialized surgical exposure for revision total knee: quadriceps snip 2005;54:225-31.
and patellar turndown. Instr Course Lect. 1999;48:149-52. 16. Malo M, Vince KG. The unstable patella after total knee arthroplasty: etiology,
2. Bonutti PM, Seyler TM, Kester M, McMahon M, Mont MA. Minimally invasive prevention, and management. J Am Acad Orthop Surg. 2003;11:364-71.
revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:69-75. 17. Mason JB, Fehring TK. Removing well-fixed total knee arthroplasty implants. Clin
3. Bourne RB. Prophylactic use of antibiotic bone cement: an emerging standard— Orthop Relat Res. 2006;446:76-82.
in the affirmative. J Arthroplasty. 2004;19:69-72. 18. McAuley JP, Engh GA, Ammeen DJ. Treatment of the unstable total knee arthro-
4. Bugbee WD, Ammeen DJ, Engh GA. Does implant selection affect outcome of plasty. Instr Course Lect. 2004;53:237-41.
revision knee arthroplasty? J Arthroplasty 2001;16(5):581-585. 19. Naudie DD, Rorabeck CH. Managing instability in total knee arthroplasty with
5. Cuckler JM. Bone loss in total knee arthroplasty: graft augment and options. J constrained and linked implants. Instr Course Lect. 2004;53:207-15.
Arthroplasty. 2004;19:56-8. 20. Parsley BS, Sugano N, Bertolusso R, Conditt MA. Mechanical alignment of tibial
6. Eisenhuth SA, Saleh KJ, Cui Q, Clark CR, Brown TE. Patellofemoral instability stems in revision total knee arthroplasty. J Arthroplasty. 2003;18:33-6.
after total knee arthroplasty. Clin Orthop Relat Res. 2006;446:149-60. 21. Rand JA. Treatment of the patella at reimplantation for septic total knee arthro-
7. Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect plasty. Clin Orthop Relat Res. 2003;416:105-9.
classification and alternatives for reconstruction. Instr Course Lect. 1999;48:167- 22. Saleh KJ, Santos ER, Rhomrawi HM, Parvizi J, Mulhall KJ. Socioeconomic issues
75. and demographics of total knee arthroplasty revision. Clin Orthop Relat Res.
8. Engh, GA: Bone defect classification. In Revision Total Knee Arthroplasty. Edited 2006;446:15-21.
by GA 23. Schoderbek RJ Jr, Brown TE, Mulhall KJ, Mounasamy V, Iorio R, Krackow KA,
9. Engh and C.H. Rorabeck. Baltimore, Maryland, Williams & Wilkins, 1997, p. 63- Macaulay W, Saleh KJ. Extensor mechanism disruption after total knee arthro-
120. plasty. Clin Orthop Relat Res. 2006;446:176-85.

10. Engh GA, Herzwurm PJ, Parks NL. Treatment of major defects of bone with bulk 24. Sheng P, Lehto M, Kataja M, Halonen P, Moilanen T, Pajamaki J. Patient outcome
allografts and stemmed components during total knee arthroplasty. J Bone Joint following revision total knee arthroplasty: a meta-analysis. Int Orthop.
Surg Am. 1997;79:1030-9. 2004;28:78-81.

11. Engh GA, Parks NL. The management of bone defects in revision total knee 25. Springer BD, Sim FH, Hanssen AD, Lewallen DG. The modular segmental kine-
arthroplasty. Instr Course Lect. 1997;46:227-36. matic rotating hinge for nonneoplastic limb salvage. Clin Orthop Relat Res.
2004;421:181-7.
12. Feinglass J, Koo S, Koh J. Revision total knee arthroplasty complication rates in
Northern Illinois. Clin Orthop Relat Res. 2004;429:279-85. 26. Toms AD, Barker RL, Jones RS, Kuiper JH. Impaction bone-grafting in revision
joint replacement surgery. J Bone Joint Surg Am. 2004;86:2050-60.
13. Hofmann AA, Goldberg T, Tanner AM, Kurtin SM. Treatment of infected total
knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clin 27. Sculco TP, Choi JC. The role and results of bone grafting in revision total knee
Orthop Relat Res. 2005;430:125-31. replacement. Orthop Clin North Am. 1998;29:339-46.

14. Jazrawi LM, Bai B, Kummer FJ, Hiebert R, Stuchin SA. The effect of stem modu- 28. Whiteside LA. Surgical exposure in revision total knee arthroplasty. Instr Course
larity and mode of fixation on tibial component stability in revision total knee Lect. 1997;46:221-5.
arthroplasty. J Arthroplasty 2001;16(6): 759-767.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
86 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 87

MINIMALLY INVASIVE TOTAL KNEE

REPLACEMENT SURGERY (FF)

SYMPOSIA AR KNEE
Moderator: William J. Maloney, MD, Stanford, CA
(a – DePuy, Medtronics, c – Zimmer, Wright Medical)

Total lknee arthroplasty has proven to be a reliable procedure for relief of pain providing
improved function. Less invasive techniques have been developed and are being adopted
for widespread use. This symposium will review the various techniques now being
performed as well as discuss potential pitfalls.

I. The Goals in Knee Arthroplasty:

William J. Maloney, MD, Stanford, CA (a – DePuy, Medtronics, c – Zimmer,
Wright Medical)
II. Less Invasive Knee Replacement Surgery: Mid Vastus Approach
Richard S. Laskin, MD, New York, NY (c, e – Smith and Nephew)

III. Less Invasive Knee Replacement Surgery: Subvastus Approach

Mark W. Pagnano, MD, Rochester, MN, (c – Zimmer, DePuy)

IV. Less Invasive Knee Replacement: The Quad Sparing Approach

Richard A. Berger, MD, Chicago, IL, Chicago, IL (a, e – Zimmer)

V. Less Invasive Knee Replacement: The Lateral Approach

Michael A. Mont, MD, Baltimore, MD, (a – TissueLink, Ossacur, e – Stryker
Orthopaedics, Wright Medical Technology)

V. Navigation and Small Incision Knee Replacement

S. David Stulberg, MD, Chicago, IL (e – Asculap)

VI. Potential Pitfalls with Navigation in TKR

Stuart B. Goodman, MD, Stanford, CA (a, e – Zimmer)

VII. Pain Control and Rehab after TKR

Lawrence D. Dorr, MD, Inglewood, CA (a, c – Zimmer)

VIII. MIS TKR: Maintaining Perspective

Robert Barrack, MD, Saint Louis, MO (c – Smith & Nephew)

IX. Panel Discussion

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
87
SYM 07:Layout 1 1/12/07 11:40 AM Page 88

THE GOALS IN KNEE REPLACEMENT SURGERY

William J. Maloney, MD

Total knee replacement is an established procedure with an b. Cementless

excellent long term track record. Many studies have document- i. Precise bony cuts
ed its effect on improving quality of life and providing durable ii. Rigid initial fixation
long term pain relief. The technical factors that are important
SYMPOSIA AR KNEE

Recent data has demonstrated that the majority of knee revi-

in achieving these results are clearly established. They include:
sions done at major centers are done less than five years after the
index operation. For example, in a study by Sharkey et al,
1. Proper Bony Cuts To Determine Implant Alignment
55.6% of the revisions they performed over a three year period
a. Femoral component rotation
were done within two years of the index procedure. In many of
b. Femoral component varus/valgus
these cases, the reasons for failure were technical.
c. Femoral component flexion/extension
d. Tibial component rotation Less invasive knee replacement surgery has gained wide popu-
e. Tibial component varus/valgus larity and in many cases is being driven by patient demand.
f. Tibial component flexion/extension Direct to consumer marketing by both physicians and industry
has made patients aware of procedures earlier than they may
2. Ligament Balancing
have been in the past. It is obvious that exposure is more lim-
a. Flexion-Extension Gap Balancing
ited with small incision surgery. This along with the fact that
i. Collateral ligaments
total knee replacement is a general orthopaedic procedure
ii. Posterior cruciate ligament
commonly down by low volume surgeons may result in an
b. Patellofemoral Tracking
increase in short term failures.
3. Implant Fixation
a. Cement
i. Adequate cement mantle
ii. Clearing excess cement

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
88 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 89

USING A MINI-MID VASTUS APPROACH

Richard S. Laskin MD

I. Some important comments at the onset PASSIVE FLEXION

• None of the approaches are MINIMAL (Webster’s Dict.
defines MINIMAL as the least possible or barely ade-
quate)

SYMPOSIA AR KNEE
• This approach attempts to decrease surgical trauma asso-
ciated with a standard medial parapatellar approach with
patellar eversion
• THE SIZE OF THE SKIN INCISION IS UNIMPORTANT
and varies dependent upon the height of the patient, the
girth of the leg, and the width of the femur
II. Mini-Mid Vastus Approach to TKR
• Surgical Incision MORPHINE SULFATE EQUIVALENTS (MG)
— 8- 14 cm anterior skin incision (length dependant on
size of patient) performed with knee in partially
flexed position over a bolster
— Mini-mid vastus capsular incision with minimal dis-
ruption of suprapatellar pouch
— Partial fat pad excision
— Medial capsular elevation
— Patella displaced laterally but not everted
— Knee hyperflexed only after femoral and tbial resec-
tions
— MMV TKR increased rate of regaining and final
amount of flexion
— MMV TKR decreased need for pain medication by
50% especially on days after the epidural catheter had
been removed
— Component position and limb alignment = for both
groups; 1 varus tibial component (86°) in each group
— All knees in both groups had varus valgus stability in
extension of 0-5° (Knee Society Rating System)
— Mean knee scores at 2 mos and 1 year higher in MMV
Mini Mid Vastus Capsular incision
group (p = .05)
• Study #2 (CORR 2005)
— MMV Incision exposure prospectively in 100 OA
patients to undergo primary TKR
— BMI, coronal deformity, nor age did not exclude
patient
— Mean follow up 2.4 years
¬ Passive Flexion (deg):
BMI < 30 122
BMI 31-39 120
BMI >40 115
MIS Instrumentation All males 118
• Modified surgical instrumentation All females 122
— No impingement of patella laterally >15° fixed coronal deformity 121
— No lateral wings on tibial cutting block < 15° fixed coronal deformity 122
— Anterior referencing ¬ Mean Knee Society Score: 94
— Low profile — Length of mid vastus split measured at start and end
• Study # 1 (CORR 2004) of procedure in subgroup of 20 patients. Initial split =
— Prospective for patients with MMV TKR 2 cm. Mean length at end of procedure was 2.5 cm. In
— Retrospective for immediately previous TKR’s through one patient split was 4 cm
standard incision — In six morbidly obese patients (BMI >40) it was nec-
— 25 in each group essary to extend the deep incision in the VMO to 5-6
cm
— In patient with a severe fixed valgus deformity it may
be difficult to expose the lateral epicondyle for releases
— One varus tibial component (86°) in patient with
BMI of 40

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
89
SYM 07:Layout 1 1/12/07 11:40 AM Page 90

— Two patellar components patellar tilt of 10° and 15° — Mean blood loss 467 cc
respectively. In all others tibial tilt was 5° or less on — Mean tourniquet time 56’
Merchant view (88 cases with no tilt at all) — Mean time to 90 deg of flexion 4.0 days
— One patient with zone IV 1.5mm radiolucency — Mean hospitalization time 4.1 days
(patient with 86° varus tibial component — Mean time to d/c cane indoors: 3.1 weeks
— One patient with zone I < 1mm radiolucency — At 4 weeks 95% could reciprocate stairs
— No vascular injuries, no fractures during surgery, no • Tips and Tricks
injuries to MCL — Use bolster under knee to achieve 45 deg of flexion
• Study #3 for surgical approach
SYMPOSIA AR KNEE

— MMV Incision exposure WITHOUT patellar eversion — For very muscular patient make 2 cm rectus/VMO
prospectively in 50 patients compared to patients with incision and then turn medially in the direction of the
medial parapatellar incision WITH patellar eversion VMO fibers
— BMI, coronal deformity, age, ROM similar in both — Hold patellar subluxed laterally with PCL retractor
groups — Sequence of bone cuts for maximum visualization:
— Measured Patella Baja by Insall Salvati and distal femur, anterior and posterior femur, tibial
Blackburne-Peale ratios plateau, chamfers, box (for PS knee only), patella
— Prevalence of patella baja statistically less in group in — Do not hyperflex knee except when inserting tibial
which patella was not everted (p <.03) component and removing excess cement
— Less patella baja (patella not everted group)correlated — Have a very low threshold to extend the skin incision
with better flexion post op and less anterior knee pain if there is tension on the end (especially distally)
— No difference in ability to properly place components — Never promise the patient a specific size of incision
nor balance the knee in those knees in which the — This is not applicable to all patients, ie: patient who is
patella was not everted obese, or has a very muscled leg, or prior open knee
• Total Personal Results surgery
— To date have performed 398 MIS TKR’s

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
90 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 91

MIS TKA WITH A SUBVASTUS APPROACH

Mark W. Pagnano, MD

Performing minimally invasive total knee arthroplasty through are placed precisely to get good exposure of the entire surface of
a subvastus approach makes sense on an anatomic basis, on a the tibia: a pickle-fork retractor posteriorly provides an anterior
scientific basis and on a practical basis. Anatomically, the sub- drawer and protects the neurovascular structures; and bent-
vastus approach is the only approach that saves the entire Homan retractors medially and laterally protect the collaterals

SYMPOSIA AR KNEE
quadriceps tendon insertion on the patella1-5. (Figure 1) and define the perimeter of the tibial bone. (Figure 4) The tib-
Scientifically, the subvastus approach has been shown, in ial resection is carried out with an extramedullary guide opti-
prospective randomized clinical trials, to be superior to the stan- mized for small incision surgery. The tibia is cut in one piece
dard medial parapatellar arthrotomy and to the so-called quad- using a narrow but thick saw blade that fits the captured guide.
sparing arthrotomy3,6,7. (Table 1) Practically, MIS TKA with a The narrow blade is more maneuverable in the smaller guide
subvastus approach is reliable, reproducible and efficient and and provides better tactile feedback for the surgeon to detect
allows the MIS technique to be applied to a broad group of when the posterior and lateral tibial cortices have been cut.
patients not just a highly selected subgroup8. (Table 2)
The femoral sizing and rotation guide is thin enough that it can
be pinned to the distal femur and the knee can still be brought
Surgical Technique
out to 60 degrees of flexion to visualize the anterior femur for
The incision starts at the superior pole of the patella, ends at the
accurate sizing. (Figure 5) At 60 degrees of flexion a retractor is
top of the tibial tubercle and measures 3.5 inches (8.8 centime-
placed anteriorly and the surgeon can see under direct vision
ters) in extension. Surgeons should start with a traditional 6 to
that the femoral cortex will not be notched. Clearing some of
8 inch incision and then shorten the incision length over time.
the synovium overlying the anterior femoral cortex helps ensure
The medial skin flap is elevated to clearly delineate the inferior
that femoral sizing is accurate. The femoral finishing guide is
border of the vastus medialis obliquus muscle. The fascia over-
adjusted medially or laterally. Femoral rotation is confirmed by
lying the VMO is left intact as this helps maintain the integrity
referencing the surgeon’s choice of the posterior condyles,
of the muscle belly itself throughout the case. The anatomy is
Whiteside’s line or the transepicondylar axis each of which can
very consistent. The inferior edge of the VMO is always found
be defined with this subvastus approach. After the femoral and
more inferior and more medial than most surgeons anticipate.
tibial cuts are made the surgeon can carry out final ligament
The muscle fibers of the VMO are oriented at a 50 degree angle
releases and check flexion and extension gap balance in what-
and the VMO tendon always attaches to the mid-pole of the
ever fashion is desired.
patella. It is very important to save this edge of tendon down to
the midpole. That is where the retractor will rest so that the Patellar preparation with this surgical approach is left until the
VMO muscle itself is protected throughout the case. The arthro- end. Cutting the patella is not required for exposure and prepar-
tomy is made along the inferior edge of the VMO down to the ing the patella last the risk of inadvertent damage to the cut sur-
mid-pole of the patella (do not be tempted to cheat this superi- face of the patella is minimized. The patella cut is done free-
orly as that will hinder, not help, the ultimate exposure.) (Figure hand or with the surgeon’s choice of cutting or reaming guides.
2) This proximal limb of the arthrotomy parallels the inferior When a patellar cutting guide is used, the trial components are
edge of the VMO and is made at the same 50 degree angle rela- removed as then the entire limb can shorten, taking tension off
tive to the long axis of the femur. At the midpole of the patella the extensor mechanism and allowing easier access to the patel-
the arthrotomy is directed straight distally along the medial bor- la for preparation.
der of the patellar tendon. A 90 degree bent-Homan retractor is
The modular tibial tray is cemented first, then the femur and
placed in the lateral gutter and rests against the robust edge of
finally the patella. The tibia is subluxed forward with the aid of
VMO tendon that was preserved during the exposure.
the pickle-fork retractor and the medial and lateral margins of
Surprisingly little force is needed to completely retract the patel-
the tibia are exposed well with 90 degree bent-homan retractors.
la into the lateral gutter. The knee is then flexed to 90 degrees
Care is taken to remove excess cement from around the tibial
providing good exposure of both distal femoral condyles.
base plate, particularly posterolaterally. The femur is exposed for
(Figure 3) If the patella does not slide easily into the lateral gut-
cementing by placing bent human retractors on the medial and
ter, typically it is because a portion of the medial patellofemoral
lateral sides above the collateral ligament insertions on the
ligament remains attached to the patella. That occurs if the prox-
femur. A third retractor is placed under the VMO where it over-
imal limb of the arthrotomy is made in too horizontal a fash-
lies the anterior femur. Cement is applied to the entire under-
ion rather than at the 50 degree angle that parallels the VMO. By
surface of femoral implant prior to impaction. Special attention
releasing that tight band of tissue the patella will translate later-
is paid to removing excess cement from the distal lateral surface
ally without substantial difficulty.
of the femur as this area is difficult to see after the patella is
The distal femur is cut with a modified intramedullary resection cemented in place. At this point The real tibial insert can be
guide. Bringing the knee out to 60 degrees of flexion better placed or a trial insert can be used at the surgeon’s discretion.
exposes the anterior portion of the distal femur. When a very The patella is cemented last. After the cement has hardened the
small skin incision is used the distal femur is cut one condyle at knee is put through a range of motion and final balancing and
a time with the intramedullary portion of the cutting guide left patellar tracking are assessed.
in place for added stability. If a slightly longer skin incision is
The tourniquet is deflated so that any small bleeders in the sub-
used the distal cutting guide can be pinned in place and both
vastus space can be identified and coagulated. The closure of the
condyles cut in a standard fashion.
arthrotomy starts by reapproximating the corner of capsule to
The proximal tibia is cut next and by doing that more room is the extensor mechanism at the midpole of the patella. Then 3
made for subsequently sizing and rotating the femoral compo- interrupted zero-vicryl sutures are placed along the proximal
nent (the most difficult part of any MIS TKA). Three retractors limb of the arthrotomy. (Figure 6) These sutures can usually be
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
91
SYM 07:Layout 1 1/12/07 11:40 AM Page 92

placed deep to the VMO muscle itself and grasp either fibrous TABLE 2.
tissue or the syovium attached to the distal or undersurface of CLINICAL RESULTS WITH THE MINIMALLY INVASIVE SUBVASTUS
the VMO instead of the muscle itself. These first 4 sutures are APPROACH IN 103 CONSECUTIVE PATIENTS WITH OSTEOARTHRITIS8
most easily placed with the knee in extension but are then tied Gender Age Weight Operative Functional Outcomes
with the knee at 90 degrees of flexion to avoid overtightening (years) (Pounds) Time mean (in days)
the medial side and creating an iatrogenic patella baja postop- (minutes)
eratively. A deep drain is placed in the knee joint and the dis- 61 Female 66 years 198 pounds 58 minutes 1. Hospital stay 2.8 days
42 Male (40-90) (137-305) (35-115) 2. Normal daily activities 7
tal/vertical limb of the arthrotomy is closed with multiple inter-
days
rupted zero-vicryl sutures placed with the knee in 90 degrees of
SYMPOSIA AR KNEE

3. No walker: 14 days
flexion. The skin is closed in layers. Staples are used, not a sub- 4. No cane: 21 days
cuticular suture. More tension is routinely placed on the skin 5. Drive 28 days
during MIS TKA surgery than in standard open surgery and our 6. Walk ½ mile 42 days
experience suggests the potential for wound healing problems is 7. Flexion at 8 weeks 116
magnified if the skin is handled multiple times as is the case degrees
with a running subcuticular closure.

Discussion
Minimally invasive total knee arthroplasty with a subvastus
approach has proved reliable, reproducible and efficient in our
experience. The technique is amenable to step-wise surgeon
learning and can be applied to a substantial range of patients
who require total knee arthroplasty not just a selected subgroup.
There are patients who are not good candidates for any MIS TKA
procedure including those with marked knee stiffness, fragile
skin, or marked obesity. Similarly, any knee with patella baja
will be markedly difficult with an MIS approach because sub-
luxing the patella laterally is often not possible. In those cases a
traditional skin incision and more extensile exposure are in the
interest of patient and surgeon alike.
Surgeons should be aware that changes in surgical technique Figure 1-A
alone are unlikely to provide the dramatic early improvements
in postoperative function that some surgeons have described
after MIS TKA. Maximizing the early gains after surgery (mini-
mal pain, early ambulation, rapid hospital discharge) typically
requires a combination of advanced anesthetic techniques, a
multimodal pain management program, a rapid rehabilitation
protocol and appropriate patient expectations. How much each
of those contribute versus how much the surgical technique
contributes to early functional improvement has not been deter-
mined scientifically.
TABLE 1.
PROSPECTIVE RANDOMIZED TRIALS OF THE SUBVASTUS
APPROACH IN TOTAL KNEE ARTHROPLASTY
Authors # Patients Study Variable Key Findings
Randomized Figure 1-B
Roysam & 89 Subvastus versus 1. Subvastus had earlier straight
Oakley7 medial parapatellar leg raising p<0.001
Approach 2. Subvastus used fewer
narcotics week one p<0.001
3. Subvastus had greater knee
flexion at 1 week p<0.001
Aglietti et al.6 60 Subvastus versus 1. Subvastus had earlier straight
Zimmer Quad-Sparing leg raising p=0.004
approach 2. Subvastus had better flexion
at 10 days p=0.01
3. Subvastus had better flexion
at 30 days p=0.03
Faure et al.3 20 Subvastus versus 1. Subvastus had greater
Medial parapatellar strength at 1 week and
1 month
approach 2. Subvastus had fewer lateral Figure 1-C
releases done
3. Subvastus was preferred by
patients 4:1

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
92 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 93

FIGURE 1 A-C. – Anatomy of the extensor mechanism.

A. The vastus medialis obliquus (VMO) tendon consistently inserts at the midpole
of the patella at a 50 degree angle relative to the long axis of the femur.
B. When looking through a surgical incision one could easily mis-identify the most
prominent part of the VMO (the point closest to the patella, akin to the bow of
the ship) as the most inferior part of the VMO. Because that most prominent
portion often lies close to the superior pole of the patella some surgeons might
then mistakenly presume that the VMO inserts at the superior pole of the patella.

SYMPOSIA AR KNEE
Additional medial dissection will delineate the inferior border of the VMO which
is more inferior and more medial than most surgeons anticipate.
Figure 2
C. The arthrotomy for the subvastus exposure parallels the inferior border of the
VMO, intersects the patella at the midpole and then is turned straight distally to
parallel the medial margin of the patellar tendon.
Figure 2. The arthrotomy starts medially along the inferior border of the VMO and
extends to the midpole of the patella at the same 50 degree angle as the muscle
fibers of the VMO.
Figure 3. With surprisingly little force the patella is retracted completely into the lat-
eral gutter. The knee is then flexed to 90 degrees providing exposure of both
condyles of the distal femur.
Figure 4. The tibia is prepared next and that is done in order to provide more work-
ing room for subsequently sizing and rotating the femoral component (the most dif-
ficult part of any MIS TKA). Good exposure of the entire surface of the tibia is
Figure 3 accomplished with 3 retractors placed precisely: a pickle-fork retractor posteriorly to
provide an anterior drawer; and bent-Homan retractors medially and laterally to pro-
tect the collaterals and define the perimeter of the tibial bone.
Figure 5. The femoral sizing and rotation guide is designed to be pinned to the dis-
tal femur and is thin enough that the knee can subsequently be brought out to 60
degrees of flexion to visualize the anterior femur for accurate sizing.
Figure 6. The tourniquet should be let down and any small bleeders in the subvastus
space should be cauterized. The closure is then done by first reapproximating the
corner of capsule at the midpole of the patella. Then 3 interrupted sutures are placed
through the deep layer of synovium to close the knee joint itself. Those 4 sutures are
tied with the knee at 90 degrees of flexion to avoid creating iatrogenic patella baja.

Figure 4

Figure 5

REFERENCES 5. Hoffman AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for pri-
1. Pagnano MW, Meneghini RM, Trousdale RT : Anatomy of the knee with special mary total knee arthroplasty. Clin Orthop 1991, 269:70-77.
reference to quadriceps sparing TKA. Clin Orthop 2006, in press. 6. Aglietti P; Baldini A: A prospective, randomized study of the mini subvastus ver-
2. Chang CH, Chen KH, Yang RS, Liu TK: Muscle torques in total knee arthroplasty sus quad-sparing approaches for TKA. Presented at the Interim Meeting of the
with subvastus and parapatellar approaches. Clin Orthop 2002, 398:189-195. Knee Society. New York, NY September 8, 2005.

3. Faure BT, Benjamin JB, Lindsey B, Volz RG, Schutte D: Comparison of the sub- 7. Roysam GS, Oakley MJ: Subvastus approach for total knee arthroplasty: a prospec-
vastus and paramedian surgical approaches in bilateral knee arthroplasty. J tive, randomized, and observer-blinded trial. J Arthroplasty 2001, 16:454-457.
Arthroplasty. 1993 Oct;8(5):511-6. 8. Pagnano MW, Leone JM, Hanssen AD, Lewallen DG: Minimally Invasive Total
4. Gore DR, Sellinger DS, Gassner KJ, Glaeser ST: Subvastus approach for total knee Knee Arthroplasty with an Optimized Subvastus Approach: A Consecutive Series
arthroplasty. Orthopedics 2003, 26:33-35. of 103 Patients. Presented at American Academy of Orthopaedic Surgeons
Annual Meeting 2005, Washington DC.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
93
SYM 07:Layout 1 1/12/07 11:40 AM Page 94

A COMPREHENSIVE PATHWAY FOR OUTPATIENT TKA

Richard A. Berger, MD

ABSTRACT Results: Ninety-eight (98%) of the 100 patients were discharged

Introduction: A comprehensive perioperative anesthesia and to home the day of surgery. Post discharge, there were no read-
rehabilitation protocol was developed and implemented missions for pain, nausea, or hypotension. There were five read-
around a minimally invasive quadriceps sparing technique to mission within three months of surgery, two for manipulations,
SYMPOSIA AR KNEE

assess the feasibility and safety of outpatient total knee arthro- one for superficial I&D, one for a GI bleed, and one for cardiac
plasty. angioplasty.
Methods: Of 264 patients undergoing primary total knee Conclusion: This minimally invasive approach to total knee
replacement the met the inclusion criteria, 100 consecutive arthroplasty combined with newer anesthetic and rehabilitation
patients were selected to receive a minimally invasive quadri- protocols allow total knee arthroplasty to be done as an outpa-
ceps sparing technique with a new comprehensive perioperative tient. Of the 100 patients enrolled in this comprehensive out-
pathway. A comprehensive perioperative management pathway patient protocol, 98% were discharged the day of surgery. The
was developed and implemented including preoperative teach- high rate of discharge to home the day of surgery was in part due
ing, regional anesthesia, and preemptive oral analgesia and to our team’s responsiveness to early signs of nausea and
antiemetic therapy. In addition, a rapid rehabilitation pathway hypotension, which were swiftly acted upon. Continue work in
with full weight bearing and range of motion was implemented this arena my make it possible to perform outpatient minimal-
within few hours after surgery. If standard discharge criteria ly invasive total knee arthroplasty in specialized surgical centers
were met the day of surgery, the patient had the option of dis- in the future.
charge to home the day of surgery.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
94 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 95

LESS INVASIVE KNEE REPLACEMENT SURGERY

Michael A. Mont, M.D.

Introduction: ¬ similar implant accuracy to standard TKA

• Significant media exposure • Gesell and Tria [17]
• Patient demand — 2 to 4 year results of minimally invasive unicondylar
• Decreased costs, development of new instrumentation and arthroplasty

SYMPOSIA AR KNEE
techniques — 47 knees in 41 patients
• Detractors describe this surgery as being “through a key- — increased range of motion
hole” — Knee Society pain score improved from 45-80
• Supporters believe MIS will become more prevalent over — function score improved from 47-78
time. — one revision
— results are at least equal to those of the standard proce-
Definition:
dure at 2 to 4 years after the surgery
• Length of the skin incision 12 to 14 cm [1,2]
• Bonutti and Mont [18]
• Other factors:
— minimally invasive surgical approach
• amount of soft tissue disruption
¬ reduces hospital stays
• muscle damage
¬ decreases postoperative pain
• patella (retraction vs. eversion)
¬ decreases rehabilitation needs
• ligament/capsular damage
¬ enables patients to return to normal function more
• dislocation of knee joint (tibia-femoral dislocation)
quickly
• outpatient or reduced hospitalization.
• Laskin RS [19]
Reports — mini mid-vastus capsular incision
• Dickstein [12] — 100 patients
— self-appraisal at 6 and 12 months post-operatively — followed up for a minimum of 2 years
— conventional TKA’s that were rated successful by surgeons — excellent results clinically and radiographically with
— 66% of patients were satisfied with their total knee restoration of stability and motion
replacement — no implant malpositioning
— “one-third of respondents expressed dissatisfaction from • Mont, Bonutti et al. (multicenter, lateral approach)
the operation” — 30 knees, 26 patients
• Bullens et al. [13] — mean age: 63 years
— patient satisfaction after TKA — mean follow up 10 months
— “concerns and priorities of patients and surgeons differ” — no anterior pain
— “it appears that surgeons are more satisfied than patients — immediate straight leg raise
after TKA” ¬ 27 of 30 knees vs 14 of 47 knees (standard approach)
• Trousdale [3] — Knee Society score: 97 points vs 91 (standard approach)
— the two greatest concerns for patients prior to undergo- • Bonutti et al.
ing total hip and total knee arthroplasty were pain and — clinical and radiographic results of minimally invasive
length of recovery. approach
• Haas et al. [14] — 166 consecutive patients (216 knees)
— mini mid-vastus approach without patella eversion — minimum two-year follow-up (range, 2 to 4 years)
— more rapid functional recovery and improved range of — 195 knees (98%) have good and excellent objective Knee
motion. Society Scores and patient satisfaction indices
• Mahoney and Schmalzried [15] — 6 knees that required a manipulation under anesthesia
— assessed quadriceps function after TKA (all doing well)
— traditional TKA at three months post-operatively: 40% of — no perioperative surgical complications
patients could arise from the chair without the use of — 5 knees have undergone reoperation;
their arms ¬ 2 for late hematogenous deep infection with one
— at six months, 64% of these patients could arise from a retained
chair without using their arms ¬ 2 tibial components were revised for chronic pain
— prolonged quadriceps weakness after conventional TKA — both components in one patient after a PCL rupture
• Mont and Ragland — 2 knees have progressive 2-3 mm radiolucencies (one
— 35% of patients stated no limitations in activity tibial and one femoral)
— patients under age of 60: only 13% stated that there were • Kolisek et al. [20]
no limitations in their activity — compared clinical, functional, and radiographic outcome
— younger, more active patients have much greater limita- of a minimally invasive, limited approach knee replace-
tions imposed by the traditional TKA, despite good to ment vs. a standard a approach
excellent Knee Society Scores — mulicenter study
• Tria and Coon [16] — 10 surgeons
— 70 minimally-invasive TKA’s — 80 knees
— early results indicate — 12 week follow-up
¬ less intraoperative blood loss — no difference in Knee Society score
¬ shorter length of stay — no difference in radiographic outcome
¬ increased range of motion • Bonutti, Mont et al. [21]
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
95
SYM 07:Layout 1 1/12/07 11:40 AM Page 96

— patients with osteonecrosis after arthroscopy • Avoid everting the patella for any period of time.
— all did well with mini-invasive approach • Downsized instrumentation.
• Use of bone platforms with bone taken out in “piece-meal”
KEY FEATURES
manner.
• The incision is approximately two times the patella length,
• “Suspended leg” technique.
(6.5 to 11.5 cm).
• Soft tissue envelope approach -- progressive flexion/exten- Conclusion
sion in the joint to the current, exposed area. As bone cuts • Not a revolution but rather an evolutionary approach.
are made, the next soft tissue envelope opens up corre- • Retraction not dislocation.
SYMPOSIA AR KNEE

spondingly. • Significant learning curve, but preliminary results are prom-

• VMO snip, 1.5-2 cm with a capsulotomy. ising.
• Knee is progressively flexed and extended and retractors are • Patient satisfaction is as important as surgeon satisfaction.
relaxed medially to expose laterally or relaxed laterally to • Future: in situ bone cuts and implantation with computer
expose medially to allow joint exposure. navigation?
• Cut the tibia and femur in situ avoiding dislocating the
tibiofemoral joint.
• Inferior and superior patellar capsular releases.

REFERENCES 12. Dickstein R, Heffes Y, Shabtai E, Markowitz E. Total knee arthroplasty in the eld-
1. Zimmer Corporation. Minimally invasive: The M/G unicompartmental knee. erly: patients’ self-appraisal 6 and 12 months postoperatively. Gerontology
Zimmer Inc; 2001. 1998;44(4):204-210.

2. Zimmer Global Webcast features live minimally invasive total knee arthroplasty 13. Bullens P, van Loon C, de Waal Malefijt M, Laan R, Veth R. Patient satisfaction
as training tool for Orthopaedic surgeons. Medical Professional [serial online]. after total knee arthroplasty: a comparison between subjective and objective out-
2003. Available at http://www.zimmer.com. Accessed June 9, 2003. come assessments. J Arthroplasty 2001;16(6):740-747.

3. Trousdale R, McGrory B, Berry D, Becker M, Harmsen W. Patients’ concerns 14. Haas SB, Cook S, Beksac B Minimally invasive total knee replacement through a
prior to undergoing total hip and total knee arthroplasty. Mayo Clin Proc mini midvastus approach: a comparative study. Clin Orthop Relat Res. 2004
1999;74:978-982. Nov;(428):68-73

4. Romanowski M, Repicci J. Minimally invasive unicondylar arthroplasty: eight- 15. Mahoney O, McClung C, dela Rosa M, Schmalzried T. The effect of total knee
year follow-up. J Knee Surg 2002; 15(1): 17-22. arthroplasty design on extensor mechanism function. J Arthroplasty
2002;17(4):416-421.
5. Buechel F. Long-term follow-up after mobile-bearing total knee replacement.
Clin Orthop 2002;404:40-50. 16. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience.
Clin Orthop Relat Res. 2003 Nov;(416):185-90.
6. Font-Rodriguez D, Scuderi G, Insall J. Survivorship of cemented total knee
arthroplasty. Clin Orthop 1997;345:79. 17. Gessel MW, Tria AJ Jr. MIS unicondylar knee arthroplasty: surgical approach and
early results. Clin Orthop Relat Res. 2004 Nov;(428):53-60.
7. Hanssen A, Rand J. A comparison of primary and revision total knee arthroplas-
ty using the kinematic stabilizer prosthesis. J Bone Joint Surg Am 1988;70:491. 18. Bonutti PM, Mont MA, McMahon M, Ragland PS, Kester M. Minimally invasive
total knee arthroplasty. J Bone Joint Surg Am. 2004;86-A Suppl 2:26-32.
8. Keating E, Meding J, Faris P, Ritter M. Long-term follow-up of nonmodular total
knee replacements. Clin Orthop 2002;404:34-39. 19. Laskin, RS. Minimally invasive total knee arthroplasty: the results justify its use.
Clin Orthop Relat Res. 2005 Nov;440:54-9.
9. Rand J, Ilstrup D. Survivorship analysis of total knee arthroplasty: cumulative
rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 20. Kolisek FR, Bonutti PM, Hozack WJ, et al. Clinical Experience using a Minimally
1991;73:397. Invasive Surgical Approach for Total Knee Arthroplasty: Early Results of a
Prospective Randomized Study Compared to a Standard Approach. J of
10. Scott W, Rubinstein M, Scuderi G. Results after knee replacement with a posteri- Arthroplasty. (In Press for publication 2006).
or cruciate-substituting prosthesis. J Bone Joint Surg Am 1988;70:1163.
21. Bonutti PM, Seyler TM, Delanois RE, McMahon M, McCarthy JC, Mont MA.
11. Stern S, Insall J. Posterior stabilized prosthesis: results after follow-up of nine to Osteonecrosis of the knee after laser or radiofrequency-assisted arthroscopy:
twelve years. J Bone Joint Surg Am 1992;74:980. treatment with minimally invasive knee arthroplasty. J Bone Joint Surg Am.
2006;88:69-75.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
96 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 97

MIS CAS TKA: RATIONALE AND PRINCIPLES:

S. David Stulberg, MD

1: The rationale for a MIS-TKA Program: 8: Navigation must be designed For MIS-TKA
• An accurate and properly executed TKA can be carried • Hardware
out safely that decreases the morbidity, accelerates the • Software
recovery and improves the outcome of the surgical proce- • Instruments

SYMPOSIA AR KNEE
dure
9: Requirements of CAS for use with MIS-TKA
2: MIS TKA exposures reduce • Safe
Visualization: • Accurate
• The “mobile window” • Efficient
• Special retractors – Time
• Unique instruments – Expense
• Altered exposures • Adaptable to MIS techniques and tools
• Multiple assistants
10: Instruments must be developed for CAS-MIS TKA:
3: Consequences of reduced visualization:
11: Surgical Technique
• Implant mal-position
1: Place Bicortical Screws In The Femur And Tibia And
• Fracture
Attach Trackers
– Femur, Tibia, Patella
2: Make Skin Incision
• Neurovascular injuries
3: Resect patella
• Compromised wound healing
4: Attach distal femoral cutting block and resect distal
• Prolonged operative time
femur
4: There are many sources of error in TKA when performed 5: Establish rotation & anterior –posterior position Of 4 in
manually: 1 Cutting Block of Proper Size
Placing cutting blocks 6: Prepare proximal tibia
Attaching cutting blocks to bone 7: Insert implants and perform reduction
Cutting through cutting blocks
12: Preliminary Results
Placing implants
13: Conclusion:
5: CAS techniques were developed to overcome limitations
Navigation & Small Incision Knee Replacement Surgery
of manual instrumentation
• Intense interest by:
6: The initial results using CAS with – Patients
Conventional Surgical Exposures: – Surgeons
• Increased accuracy – Companies
• Fewer outliers • Belief by surgeons that MIS and CAS will eventually
merge!
7: The Rationale for CAS + MIS-TKA
• Optimism that ultimate consequence of MIS-CAS TKA
• CAS
will be very positive, in spite of substantial current con-
– Optimize the accuracy of TKA
cerns about inflated claims and ethical mis-adventures
– Reduce the need for direct visualization of surgical
anatomy
THIS SHOULD BE A STRONG STIMULUS FOR THE
• MIS
EVOLUTION & REFINEMENT OF MIS-CAS TKA
– Reduce peri-operative morbidity
TECHNOLOGIES
– Enhance post-operative function

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
97
SYM 07:Layout 1 1/12/07 11:40 AM Page 98

MIS TKA: MAINTAINING PERSPECTIVE

Robert L. Barrack, MD

I. Avoiding Structures at Risk 2. Malrotation – Whiteside’s line, epicondyles

A. Skin, soft tissue 3. Medial translation – remove osteophytes
1. Patient selection – obese, RA, scleroderma C. Tibial errors
2. Soft tissue characteristics – turgor, mobility, “U sign” 1. Varus alignment – inadequate lateral resection
SYMPOSIA AR KNEE

of Scuderi 2. Internal rotation

B. Patellar tendon
III. Component Fixation
1. Avoid excessive tension
A. Cementless – imprecise ruts; lack of immediate stability
2. Pin in tubercle
B. Cemented
3. Partial fat pad resection
1. Suboptimal interface – clear soft tissue at periphery;
4. Protect during tibial cut
clean, dry interface; pressurization, short stems/keels?
C. Medial Collateral Ligament
2. Retained cement
1. Adequate Medial Release
2. Visualize, protect with retractors IV. Ligament Balance, Stability
A. Too tight -- underresection of bone
II. Component Alignment, Avoiding Common Errors
B. Too loose – risk of nonmodular components
A. Major contributing factors
C. Importance of trials
1. Exposure, visualization, retractors
2. Knee position during each step; “mobile windows” V. Conclusion
3. Hard bone, small instruments Without careful patient selection and meticulous surgical
B. Femoral Errors technique, MIS can be a major risk factor for early failure of
1. Anterior cut – notching, oversizing; visualize anterior TKA
cortex

REFERENCES 3. Scuderi GR. Preoperative Planning and Perioperative Management for Minimally
1. Berend KR, Lombardi AV Jr. Avoiding the Potential Pitfalls of Minimally Invasive Invasive Total Knee Arthrplasty. Am J Orth. July:4-6, 2006.
Total Knee Surgery. Orthopedics. Nov:1326-1330, 2005. 4. Scuderi GR. Minimally Invasive Total Knee Arthroplasty: Surgical Technique. Am
2. Tria AJ Jr. Advancements in Minimally Invasive Total Knee Arthroplasty. J Orth. July:7-11, 2006.
Orthopedics. Aug:s859-s863, 2003. 5. Rosenberg AG. The Surgeon Skill Set in Minimally Invasive Total Knee
Arthroplasty. Am J Orth. July:30-35, 2006.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
98 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 99

POTENTIAL PITFALLS WITH NAVIGATION IN TKR

Stuart B. Goodman, MD

Navigation systems used in conjunction with TKR have the In a second study, the same orthopaedic surgeons used four
potential to improve prosthetic alignment and knee kinematics, computer-assisted techniques that required identification of
and limit outliers known to be associated with suboptimal clin- anatomical landmarks on the tibia and one that used tradition-
ical outcomes. Image-free navigation systems rely on the local- al extramedullary instrumentation (a tibial base plate and guide

SYMPOSIA AR KNEE
ization of specific anatomic landmarks intra-operatively and rod) to establish tibial rotational alignment axes on the cadaver
computer algorithms to guide the surgeon in performing bone legs. The orientations of these axes were recorded with a navi-
cuts and soft tissue balancing during TKR. However, if the local- gation system. Two of the computer-assisted techniques (the
ization process is not accurate and repeatable, the surgeon may axes between the most medial and lateral border of the tibial
make erroneous decisions during the surgical procedure. We plateau, and between the anterior tibial crest and the PCL) and
have studied the variability associated with femoral and tibial the traditional extramedullary technique were least variable.
rotational alignment techniques to determine whether the use Interestingly, computer-assisted techniques that used the tibial
of a computer-assisted surgical navigation system reduced this tubercle (the axes between the medial border of the tubercle and
variability. the PCL, or medial 1/3 of the tibial tubercle and the PCL) were
most variable. Compared to other techniques, the axis between
In one study, eleven orthopaedic surgeons used five alignment
the medial border of the tibial tubercle and the PCL was signif-
techniques (including four traditional techniques and one com-
icantly internally rotated. No technique led to consistent rota-
puter-assisted technique) to establish femoral rotational align-
tional alignment of the tibial component. Thus, navigation sys-
ment axes on ten cadaveric specimens. The orientation of these
tems that rely on identification of specific anatomic landmarks
axes was recorded with use of a navigation system. These derived
do not appear to provide a more reliable means of establishing
axes were compared with a reference transepicondylar axis on
rotational alignment than existing traditional techniques.
each femur that was established after complete dissection of all
soft tissues. All techniques resulted in highly variable femoral Current navigation systems have been shown to improve align-
rotational alignment, which was dependent on the particular ment of TKRs in the frontal plane. However, navigation should
surgeon performing the alignment procedure. The alignment optimize placement of the prosthesis in the frontal, sagittal, and
errors ranged from 13° of internal rotation to 16° of external transverse planes. Algorithms have recently been developed by
rotation. Only 17% of the knees were rotated <5° from the ref- our group to estimate the 3-dimensional location of the ankle
erence transepicondylar axis. The computer-assisted navigation and hip joints. Once these points are precisely located, align-
technique that relied on directly digitizing the femoral epi- ment of the mechanical axis in the frontal and sagittal planes
condyles to establish a femoral alignment axis was no more reli- can be accurately delineated. A future challenge of navigation is
able than traditional techniques. to develop methods to aid the surgeon in accurate placement of
TKRs in the transverse plane.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
99
SYM 07:Layout 1 1/12/07 11:40 AM Page 100

PAIN CONTROL AND REHABILITATION AFTER TKR

Lawrence D. Dorr, MD

Pain management after total knee replacement can be success- that is found to be best for them during their hospitalization
fully accomplished without the use of routine parenteral nar- plus Celebrex twice a day for three weeks and liberal use of ice.
cotics. The avoidance of routine parenteral narcotics is very
Postoperative rehabilitation begins with immediate ambulation
important for the satisfaction of the patient. Nausea and vom-
SYMPOSIA AR KNEE

after return to the floor following surgery. The initial physical

iting after the operation are the most commonly associated
therapy session includes range of motion of the knee and this
postoperative events with patient dissatisfaction. By avoiding
can be easily accomplished with the femoral nerve catheter in
parenteral narcotics, the threat of respiratory depression, urinary
place. The first physical therapy session, even if it is the morn-
retention, gastrointestinal ileus, as well as hallucinations are
ing after surgery, is always done with the femoral nerve catheter
essentially eliminated. With the pain management program
in place to allow the patient to initially bend the knee without
described, which uses epidural anesthesia, intraoperative injec-
any significant pain which gives them confidence in their abili-
tions into the knee, and oral medications, the incidence of nau-
ty to flex. Gait training emphasizes a heel-toe gait to return the
sea was 21%, mostly in the recovery room with emesis in only
gait pattern to one that allows phasic firing of the muscles of the
1.4%. This compares to the incidence of nausea with DepoDur
knee which helps promote range of motion. Patients who can
of 78% and vomiting of 43%. Urinary retention occurred in
do so are taught exercises and a walking program and not sent
3% of patients compared to 60% with epidural morphine and
to formal physical therapy. Patients who require supervision
40% of patients with PCA morphine. There was no respiratory
have home physical therapy initially sent to them and then sub-
depression or ileus in our patients.
sequently can go to physical therapy as needed. It is absolute-
The program used by us included pain medication, Cox-2 ly critical that patients are educated not to become too sore with
inhibitors, antiemetics, and Tylenol which are given preopera- their recovery and rehabilitation because that will promote stiff-
tively and then continued postoperatively. These medications ness of the knee. When patients become sore and stiff in the
are used to be able to block pain at the spinal cord and central postoperative period, therapy is discontinued until the soreness
levels. A local wound injection intraoperatively of Ropivacaine, is controlled and then begun again at a level that will control the
morphine, Depo-Medrol and epinephrine is given to block the pain of the patient. Patients are warned that the first month
local pain receptors. Anesthesia is an epidural (a short dura- will be particularly sore and swollen with their knee and during
tion spinal can also be used) that does not include morphine. that time they must control their activities to control their pain.
Postoperatively a femoral nerve catheter is used through the first For example, patients who have complaints of significant pain
night for pain relief and removed the following morning. The at night and inability to sleep are simply doing too much activ-
pain control is managed with continuation of the oral medica- ity during the day and will need to reduce that activity to con-
tions given preoperatively in a preemptive manner every four trol their night time discomfort. It takes three months for a
hours. Patients are discharged home with the pain medication patient to have a sense of free flexibility of the knee.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
100 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 101

CONTROVERSIES AND NEW OPERATIVE

SYMPOSIA FOOT/ANKLE
TECHNIQUES FOR THE TREATMENT OF
COMMON FOOT AND ANKLE OPERATIVE
PROCEDURES (D)
Moderator: Brian G. Donley, MD, Cleveland, OH (e - Wright Medical)
The advantages and disadvantages of traditional and innovative surgical treatments for
common foot and ankle problems will be described and debated by faculty. Emphasis will
be on surgical technique tips designed to improve patient outcomes and avoid
complications.

I. Introduction:
Brian G. Donley, MD, Cleveland, OH (e - Wright Medical)

II. Distal Chevron & Akin Osteotomy

Brian G. Donley, MD, Cleveland, OH (e - Wright Medical)

III. Peroneal Tendon Tears/Instability

Steve L. Haddad, MD, Glenview, IL (a,e - DePuy)

IV. Insertional Achilles Tendon Disorders

Tom G. Padanilam, MD, Holland, OH (n)

V. Case Presentation & Discussion/Questions

VI. Hallux Rigidus

John G. Anderson, MD, Grand Rapids, MI (n)

VII. Lateral Ankle Instability

Bruce E. Cohen, MD, Charlotte, NC (c, e - Wright Medical Techology)

VII. Case Presentation & Discussion/Questions

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
101
SYM 07:Layout 1 1/12/07 11:40 AM Page 102

MILD TO MODERATE BUNION: DISTAL CHEVRON &

AKIN OSTEOTOMY
Brian G. Donley, MD
SYMPOSIA FOOT/ANKLE

CHEVRON OSTEOTOMY allowing for visualization of the joint

6. Using the microsagittal saw:
I. Introduction
a. Resect the medial prominence just medial to the
A. General comments
sulcus and exit proximally at the junction of the
1. One of several distal osteotomies for correction of hal-
head and shaft – in line with the medial border of
lux valgus with a mild degree of metatarsus primus
the foot, not the diaphysis
varus
b. Beginning at the center of the head and exiting dor-
a. Alternative to modified McBride
sally, perform the dorsal portion of the v-osteoto-
2. Originally described by Corless (1976) and popular-
my (apex distal)
ized by Austin (1981) and Ken Johnson (1979)
7. With a towel clamp holding the shaft of the
B. Comparison with other distal osteotomies
metatarsal (or your opposite index finger compressing
1. Advantages
into the 1st web space) and the thumb on the distal
a. Increased stability
fragment, translate the distal fragment laterally
b. Minimal shortening
approximately 4-5 mm and impact it in place with
c. Relatively simple bone cut
firm pressure
d. Predictable, fairly rapid healing
8. Stabilize the osteotomy with a 0.045-inch K-wire and
e. Simple fixation (percutaneous K-wire)
then fixate with 2.4 solid screw, flat head (modular
2. Disadvantages
hand set)
a. May not completely correct the sesamoid position
9. With the microsagittal saw, excise the remaining
b. Derotation of metatarsal not possible
prominence created by shifting the metatarsal flush to
1) Very limited to no ability to plantarly translate
the shaft
metatarsal (in cases where there is a callus or
10. Perform capsular correction
excessive pressure underneath the second
a. Excise redundant capsule and then close with 2-0
metatarsal)
suture
2) Conflicting results in elderly – recent reports
b. Plantar arm closure/advancement allows for
positive (Anderson/Gill), combination of
sesamoid reduction
Chevron and Akin in the elderly described
11. Hold the toe in slight overcorrection (slight varus)
(Tollison/Baxter)
during capsular closure
3) Limited correction of metatarsus primus varus
12. Skin closure
II. Pre-op Decision Making 13. Apply a compression dressing
A. Indications: B. Surgical pitfalls
1. Symptomatic mild deformity 1. Excessive:
2. IM < 13, HV < 25 a. Soft-tissue stripping
3. No significant sesamoid subluxation b. Resection of prominent medial eminence
4. No significant pronation c. Removal of metatarsal head
5. Passively correctable with good ROM 2. Improper osteotomy
B. Contra-indications a. Apex too distal or proximal
1. Severe deformity b. Not parallel in medial-lateral plane
2. Age is relative, can do in patients > 50
IV. Postoperative Course
3. Arthrosis of joint
A. Dressing change each 7-10 days
C. Considerations
B. Suture removal and xray at 3 weeks
1. Biplanar osteotomy for > DMAA
C. Crutches 1 week
2. Lateral release for > HV angle with IM < 13
D. Walk on heel 2 weeks in post-op shoe
3. Akin Osteotomy
E. Wt bear as able in post-op shoe 3 weeks
II. Surgical Management F. Toe spacer 6 weeks in regular shoe
A. Technique G. 12 weeks post-op regular shoe without spacer
1. Make a medial longitudinal incision (approximately
V. Results for Chevron Osteotomy
4.5 cm) at the junction of the plantar and dorsal skin
A. Complications
2. Perform careful dissection down to the capsule –
1. Recurrence of hallux valgus, 10%
avoid cutaneous nerve dorsally
2. Displacement of osteotomy, 1.8 to 12% without fixa-
3. Within this plane between the dorsal medial cuta-
tion
neous nerve and the plantar medial hallucial nerve,
3. Displacement with fixation, 0%
make a capsulotomy that will allow for later repair
4. Avascular necrosis, 0 to 20%
(i.e. L-shpaed, transverse or V-Y
a. extraosseous blood supply to 1st MTP
4. Use sharp dissection to elevate the capsule off the
b. safe zone- Jones, 1995- proximal to lateral capsular
head (medially) and proximally to the metaphyseal
attachment
flare – avoid excessive exposure dorsally
5. Hallux varus, very low incidence
5. Perform distal dissection to the proximal phalanx,
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
102 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 103

6. Some stiffness of MTP joint, 22% J. Intra operative radiograph can confirm correct location
7. Stress transfer, very low incidence (extra-articular) and orientation (perpendicular to long
8. Fracture of metatarsal head, very rare axis) for osteotomy cut
9. Nonunion, < 1 % K. Remember joint surface of PP is concave
10. Sensory loss- 0-17% L. Leave lateral cortex intact
M.Make another osteotomy cut 3 mm distal to take medial
AKIN OSTEOTOMY
based wedge of bone

SYMPOSIA FOOT/ANKLE
I. Indications N. Manually close osteotomy site
A. Hallux valgus interphalangeus O. If osteotomy does not close, then further weaken lateral
B. Recurrent hallux valgus cortex by saw or multiple K-wire drill holes
C. In combination with another bunion procedure P. Can correct some pronation with rotation of distal frag-
ment
II. Contraindications
Q. Stabilize osteotomy (can use staple, suture, K-wire,
A. Not to be used as primary procedure for hallux valgus
absorbable pin)
III. Technique R. Approximate periosteum as able
A. Longitudinal medial midline skin incision S. Close skin
B. Protect dorsal and plantar cutaneous nerves as capsule is
IV. Postoperative Management
exposed
A. As per primary bunion procedure
C. Perform inverted L-capsulotomy if combining with a
B. If isolated procedure, weight bearing as tolerated in post-
bunion procedure
operative shoe
D. Perform bunion procedure
E. Make longitudinal medial midline periosteal incision V. Complications
over proximal part of proximal phalanx A. Joint injury
F. Do not damage vertical limb of capsular incision. 1. Remember concavity of proximal phalanx
G. Dorsal and plantar sub periosteal dissection around B. FHL adhesions
proximal phalanx 1. Remember sub periosteal retractors when making
H. Place baby curved retractors subperiostally around the osteotomy cuts
proximal phalanx to protect the FHL C. Mal-union
I. Make transverse ostetomy just distal to joint with thin saw 1. Use adequate fixation

REFERENCES 7. Horne G, Tanzer T, Ford M: Chevron osteotomy for the treatment of hallux val-
1. Plattner PF, Van Manen JW: Results of Akin type proximal phalangeal osteotomy gus. Clin Orthop 183:32-36, 1984.
for correction of hallux valgus deformity. Orthopaedics 13:989-996, 1990. 8. Johnson KA, Cofield RH, Morrey BF: Chevron Osteotomy for hallux valgus. Clin
2. Akin OF: The treatment of hallux valgus: A new operative procedure and its Orthop 142:44-47, 1979.
results. Med Sentinel 33:678-679, 1925. 9. Johnson JE, Clanton TO, Baxter DE, Gottlieb MS: Comparison of Chevron
3. Corless JR: A modification of the Mitchell procedure. J Bone Joint Surg 58- osteotomy and McBride bunionectomy for correction of mild to moderate hallux
B:138,1976. valgus deformity. Foot Ankle 12:61-68, 1991.

4. Austin DW, Leventen EO: A new osteotomy for hallux valgus: a horizontally 10. Mann RA, Donatto KC: The chevron osteotomy: a clinical and radiographic
directed V displacement osteotomy of the metatarsal head for hallux valgus and analysis. Foot Ankle Int 18:255-261,1997.
primus varus. Clin Orthop 157:25-30, 1981. 11. Meier PJ, Kenzora JE: The risks and benefits of distal first metatarsal osteotomies.
5. Hartrup SJ, Johnson KA: Chevron osteotomy: analysis of factors in patients' dis- Foot Ankle 6:7-17, 1985.
satisfaction. Foot Ankle 5:327-332, 1985. 12. Pring DJ, Coombs RRH, Closok JK: Chevron or Wilson osteotomy: a compari-
6. Hirvensalo E, Bostman O, Tormala P, Vainionpaa S, Rokkanen P: Chevron son and follow-up [abstr]. J Bone Joint Surg 67B:671-672, 1985.
osteotomy fixed with absorbable polyglycolide pins. Foot Ankle 11:212-218, 13. Resch S, Stenstrom A, Gustafson T: Circulatory disturbance of the first metatarsal
1991. head after Chevron osteotomy as shown by bone scintigraphy. Foot Ankle
13:137-142,1992.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
103
SYM 07:Layout 1 1/12/07 11:40 AM Page 104

COMMON PERONEAL TENDON PROBLEMS

Steven L. Haddad, MD

1. Anatomy i. Antiglide plate for lateral malleolar fracture

a. Blood supply (Peterson, et.al. Acta Orthop. Scand. 71, 1. 70 patients
SYMPOSIA FOOT/ANKLE

2000) 2. 30 patients (43%) had hardware removed

i. Injection and immunohistochemical study (more for peroneal tendon irritation
accurate) a. Peroneal tendon lesions identified in 9
ii. Peroneal artery via the mesotenon (30%) of these pts.
1. Enters posteriorly 3. Placing the distal end of the plate distal to
iii.Vessels within tendon (intratendinous network) much the proximal third of the lateral malleolus
less than mesotenon did not cause lesions (location of the plate
1. Distribution is non-homogenous was not important)
a. Peroneus brevis avascular zone a. UNLESS a screw was placed in the most
i. Fibular groove (squeezed between longus and distal hole, and the head was prominent
bone) or set obliquely in the hole
b. Peroneus longus avascular zone
5. Peroneal Tendon Subluxation/Dislocation
i. Between curve of fibula and peroneal trochlea
a. Monteggia (1803)
of calcaneus (anterior portion against
i. First description of peroneal tendon dislocation
trochlea)
b. Acute dislocation often mistaken as an ankle sprain
ii. Tendon changes direction as courses around
i. 0.5% of all ski injuries
cuboid
ii. 71% related to alpine skiing
c. These are the locations of most tears
c. Anatomy
b. Interestingly, correlates exactly with Burman’s 1934
i. Peroneal tendons run through fibro-osseous tunnel at
description of the location of peroneal tenosynovitis
the distal fibula
(Ann Surg 100, 1934)
ii. Bounded posterolaterally by the superior peroneal
i. Posterior to the lateral malleolus (brevis)
retinaculum
ii. Peroneal trochlea of the calcaneus (longus)
1. Main restraint to prevent dislocation
iii.Cuboid (longus)
2. Averages 10mm to 20mm in width
2. Function 3. Inserts in calcaneus in 30%, the Achilles tendon
a. 63% hindfoot eversion sheath 60%, and the Achilles tendon in 10%
i. Longus 35% iii.Depth of groove variable
ii. Brevis 28% 1. enhanced by osseous ridge with fibrocartilaginous
b. 4% total plantarflexion strength cap
i. Gastroc 87% overall 2. SPR blends with periosteum in on lateral fibula
d. Mechanism
3. Ruptures
i. Sudden forced dorsiflexion and inversion injury
a. Concomitant tears of peroneus longus and brevis
1. Simultaneously violent contracture of peroneal ten-
(Myerson, FAI 25(10), 2004)
dons
i. 29 feet over 4.6 years follow-up
2. Typically retinaculum stripped off the fibular inser-
ii. 91% received normal or moderate peroneal strength
tion or avulsed with small fleck of fibular cortex
iii.Concurrent procedures performed on all patients to
e. Distal Peroneus Brevis Muscle
correct deformity simultaneously
i. Implicated in chronic SPR attenuation
1. Lateral ligament reconstruction
1. Peroneal tendon dislocation
2. Closing wedge calcaneal osteotomy
2. Peroneus brevis split tears
iv. Complications in 31% of feet
ii. Freccero (FAI 27(4), 2006)
1. Group 1 = surgery revealed documented tear in
peroneal tendon
2. Group 2 = lateral ankle pain, surgery revealed NO
tear within peroneal tendon
3. Group 3 = patients undergoing MRI ankle for dif-
ferent reasons (NO lateral ankle pain)
f. Physical Examination
i. Passive circumduction of the ankle may reveal sublux-
ation or dislocation
ii. Patient dorsiflexes and everts the foot from a plan-
tarflexed and inverted position
1. Add resistance in an attempt to reveal dislocation
1. Adhesive tendonitis
g. Grades
2. Sural neuritis
i. Eckert and Davis (JBJS, 1976)
3. Wound dehiscence
1. Grade 1
4. Hardware Irritation
a. retinaculum is elevated from the lateral malleo-
a. Weber (FAI 26(4), 2006)
lus with the tendons lying between the bone

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
104 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 105

and periosteum 1. tie both sutures over the lateral wall of fibula (there
2. Grade 2 will be 2 horizontal mattress sutures through the 4
a. Fibrocartilaginous ridge elevated with the reti- holes)
naculum attached 2. this draws the retinaculum beneath the lateral wall
b. Tendons displaced beneath the ridge of the fibula, protecting the tendons from the
3. Grade 3 exposed bone
a. Thin cortical fragment is avulsed from the fibula x. suture the remaining retinaculum (that which was

SYMPOSIA FOOT/ANKLE
with the tendons displaced beneath the fibular reflected over the fibula) back over the newly sutured
fragment retinaculum (posterior portion) using absorbable
b. Only one visible on plain radiographs suture
h. Imaging 1. provides second level of stability
i. Routine AP, lateral, mortise radiographs may show 2. provides coverage for ethibond sutures
small flake of fibular cortex xi. let down tourniquet to achieve meticulous hemostasis
1. Ankle stress xrays may rule out ankle instability as 1. limits scar
the source of pain xii. immobilization no longer than 3wks
ii. CT scan may reveal shallow groove on axial cuts 1. begin passive ROM no later than 3wks, to limit scar
1. 18% of chronic dislocation patients g. Pressure Effects of Groove Deepening Procedures
iii.MRI may reveal peroneal tendon injury i. Title, et.al. (FAI, 26(6), 2005)
1. Biomechanical study of pressure reduction with
6. Reconstruction
groove deepening
a. Clancy (JBJS 61A, 1979)
a. Placed Tekscan sensor pads at 3 locations in the
b. First to suggest fibula groove deepening procedure….
fibular groove (proximal, middle, and distal)
c. Posterolateral incision, hugging posterior fibula
i. determine change in tendon pressure follow-
d. Open retinaculum 3mm posterior to posterior border of
ing groove deepening procedure
fibula
b. Loaded ankle to simulate WB
i. Leave a cuff posterior to this attachment to the fibula
ii. Statistically significant decrease in pressure at middle
ii. Carry this dissection past tip of fibula
and distal groove following deepening
e. Reflect retinaculum anteriorly to expose lateral wall fibula
iii.Suggest that groove deepening assists in relieving pres-
i. Full thickness flap created
sure on the tendons
f. Cut posterior fibula very thin, with microsagittal saw
1. In addition to prevention of dislocation
i. Cut 3cm segment, beginning at tip and moving proxi-
h. Results
mally
i. Porter, et.al. (FAI 26(6), 2005)
1. cut is made from lateral to medial, leaving medial
1. 13 athletes, average age 24 yrs, 35mos f/u
cortex intact
2. Complete removal of posterior groove (not hinged)
ii. Leave periosteum intact to minimize scar
3. Aggressive rehab protocol
iii.Cut superior and inferior limbs (lateral to medial)
a. Active ROM begun 1 week after surgery
using thin osteotome or chisel
b. Biking with stirrup brace at 3wks after surgery
iv. Reflect this posterior fibula bone flap using a wide,
4. All returned to sport 3 months after surgery
straight osteotome
a. 8/14 (57%) same sport
v. Use curette and high speed burr (iced irrigation) to
5. 9/14 (64%) equal ROM ankles
create depth of groove, removing 1cm bone
a. Remaining 36% within 5° opposite ankle
1. make sure burr is used at proximal segment, to
6. 4/14 (29%) pain free
insure appropriate flap replacement within lateral
a. 71% with mild pain that did not limit activity
cortex of fibula
7. Summary
vi. make 4 drill holes in lateral fibula, spacing 7mm, with
a. Peroneal tendon pathology is wide ranging
.062 K-wire
b. Look for split tears/ruptures within tendons at
vii. repair any tears within peroneal tendons
points of decreased vascularity within tendon
viii. tamp flap of fibula under “shelf” of lateral fibula
c. Use fluoroscopic imaging during hardware
cortex
placement in sensitive areas
ix. suture pattern (using 2-0 ethibond) is from lateral
d. Repair symptomatic dislocating peroneal ten-
fibula (lateral to medial), then through lateral retinac-
dons to avoid rupture
ulum (suture placed in a horizontal mattress fashion,
with 1cm bridge, preserving at least 6mm of retinacu-
lum for imbrication beneath fibula shelf). Final limb
of suture from medial to lateral through the next
proximal hole.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
105
SYM 07:Layout 1 1/12/07 11:40 AM Page 106

HALLUX RIGIDUS
John G. Anderson, MD

• Degenerative arthritis of the 1st MTP Conservative Treatments

• Limited joint motion, spurring, & pain • Cortisone injections
SYMPOSIA FOOT/ANKLE

• Varying degrees of severity • NSAIDs

• Typically from “wear and tear” • Orthotics/ Springlite Plate/ Morton’s Extension
• Trauma may be a factor (most commonly repetitive micro- • Shoe modifications
trauma) • Work and recreational activity changes
• 2nd to hallux valgus in frequency of 1st MTP pathology
Surgical Treatment Options:
Pathophysiology – Cheilectomy
Bone proliferation – Osteotomies
Cartilage wear, starts dorsally and laterally – Resection Arthroplasty
Decreased ROM – Joint Replacement
Pain secondary to joint synovitis, dorsal bone impingement, – Joint Arthrodesis/Fusion
soft tissue impingement, bone on bone – Interpositional Arthroplasty
Staging and Classification Cheilectomy
Hattrup SJ & Johnson KA • Resection of bone spurs.
• Hattrup SJ, Johnson KA: Subjective results of hallux rigidus • Remove dorsal 25-33% of metatarsal head
following treatment with cheilectomy. Clin Orthop. 1988 • Should obtain 70-90 degrees of dorsiflexion intraoperatively
(226): 182–91 • Final ROM will be less than this
• Grade I • Only possible in early stages of disease.
– Joint space maintained • Most of the cartilage must still be viable.
– Minimal osteophytes • Spurs may return with time.
• Grade II • 92% good to excellent results in terms of pain relief and
– Larger osteophytes function (stage 1 and 2).
– Subchondral sclerosis
Proximal Phalangeal Osteotomy (Moberg)
• Grade III
• Joint preserving – decompresses joint
– Complete loss of visible joint space
• Increases dorsiflexion at expense of plantar flexion
– Subchondral cysts
• Improved ROM seen in stage 1 and 2
– Osteophytes
– Adolescent rigidus, running athlete
– Hypertrophy of sesamoids
– Combine w/ cheilectomy for those lacking dorsiflexion
Coughlin M & Shurnas P
• Coughlin M, Shurnas P. Hallux Rigidus: Grading and long- Results (Easley)
term results of operative treatment. J Bone Joint Surg., 2003 • 57 patients, minimum 3-year follow-up
85-A(11): 2072-88 • AOFAS score improved from 45 to 85 points
• Grade 0 • 90-96% satisfaction
• 40-60 degree dorsiflexion or 10-20% less than opposite side • Dorsiflexion improved ~ 20 degrees
• Normal xrays • Progression of grade in >50% with time
• No pain. Only stiffness
Decision Making
• Grade I
Hattrup and Johnson
• 30-40 degree or 20%-50% less dorsiflexion than opposite
• Grade 1: Cheilectomy
• Dorsal osteophytes
• Grade II: Cheilectomy, +/- Moberg
• Minimal joint space narrowing, periarticular sclerosis or
• Grade III: Arthrodesis, excisional arthroplasty
head flattening
• Mild or occasional pain and stiffness, at extremes of motion Results
• Grade II • Only 53% satisfaction, 30% dissatisfied
• 10-30 degrees or 50-70% less dorsiflexion than opposite • Inclusion of grade 3 patients
• Dorsal, lateral, +/- medial osteophytes • Most failures were grade 3
• <25% of dorsal joint space involved
Decision Making
• Mild to moderate joint space narrowing
Coughlin and Shurnas
• Moderate to severe pain occurring near extremes of motion
• Cheilectomy used w/ predictable success to treat Grades 1 &
• Grade III
2, select Grade 3
• <10 degrees or 75-100% loss of dorsiflexion than opposite
• Grade 4 & those Grade 3 w/ < 50% of met head cartilage
• Substantial joint space narrowing, periarticular cysts, >25%
remaining at time of surgery should be treated w/ arthrode-
of joint involved
sis
• Constant pain and substantial stiffness at extremes but not
at midrange Cheilectomy Results
• Grade IV • 9.6 years follow-up, 93 feet (80 patients)
• Same criteria as Grade III but pain occurs at midrange of • 96% good to excellent results – cheilectomy
motion • Outcomes correlated with the stage
• Approx. 20 degree average improvement in ROM
• Cheilectomy does not alter natural progression of disease
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
106 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 107

1st MTP Arthrodesis/Fusion Interpositional Arthroplasty (Mroczek et al; Lau et al)

• Considered ‘gold standard’ in severe DJD • Remove spurs from joint (cheilectomy)
• Remove the spurs and diseased cartilage • Oblique mini-Keller
• Fuse the joint together – no motion remains • Increase motion/reduce pain
• Reduces the pain and size of the joint • Alternative to arthrodesis in severely arthritic joint
• Very good long-term results (95% G/E)
EDL Capsular Interposition Results (Hamilton et al)
Surgical Options: Arthrodesis EDL Capsular Interposition 34 feet with follow-up

SYMPOSIA FOOT/ANKLE
• Some limitations in activities • Significant improvement in pain & function
– Can’t tolerate squatting, high heels • Ave 50o df ; all with 4/5 pf strength
• Changes in gait pattern • “In patients with severe hallux rigidus and nearly equal
– Decreased step length length of first and second metatarsals, capsular interposition
– Earlier heel off arthroplasty offers a surgical option that relieves pain with-
• Possible nonunion, neighbor joint DJD out sacrificing motion or strength.”
Arthrodesis Results (Coughlin) Gracilis Bundle Interposition Results (Coughlin et al)
• 6.7 years follow-up, 34 feet (30 patients) • 7 feet with follow-up
• 94% fusion rate • Patient overall satisfaction
• 100% good to excellent results – Excellent = 3; Good = 4
• Ave AOFAS = 86 (range, 80-95)
Keller Resection Arthroplasty
• All able to walk in comfortable shoes w/o impingement
• Best in patients with low physical demands
• Average recovery time = 3 months (range, 2.5-3.5)
• Can be successful in reducing pain
• Risk of transfer metatarsalgia (avoid if long 2nd or short 1st Allographic Interposition (Lee, Bertlet, personal communica-
MT) tion)
• Can lead to floppy /non-functional great toe • Benefit of full cheilectomy & joint release
• Reduces the pain and size of the joint
Prosthetic Joint Arthroplasty
• Maintain/improve joint motion
• Metallic wear debris & osteolysis can occur in titanium
• No additional morbidity from harvesting tendon from
hemi-implants (Ghalambor et al)
patient
• 71% of silicone 1st MTP implants have evidence of silicone
granulomatous disease (Rahman et al) Discussion
• Hemiarthroplasty results 70% G/E at short term followup • Excellent Early Results and Lack of Complications
(authors experience) ==> Minimally Invasive Nature of Technique
• Other studies show >90% G/E (Townley et al) • Can be used as first surgical intervention for treatment of
• Overall results disappointing at 3-year follow up advanced hallux rigidus in young and active patients
(Fuhrmann, et al) – Offers opportunity to maintain an active lifestyle
– Reserves possibility for more aggressive surgical options
Interpositional Arthroplasty
should condition progress
EDL/Capsular Technique
• Additional follow-up is needed to assess long-term efficacy
• Hamilton WG, O'Malley MJ, Thompson FM, Kovatis PE.
of procedure
Capsular interposition arthroplasty for severe hallux rigidus.
Foot Ankle Int 1997, 18(2). Summary
Gracilis Tendon/Bundle Technique Gold standard remains:
• Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for hallux cheilectomy in stage 1-2, some select stage 3
rigidus. Foot Ankle Int 2003 Sept, 24(9). fusion in stage 3-4
Consider other options in young active patients to preserve
motion

REFERENCES 8. Coughlin MJ, Abdo RV. Arthrodesis of the first metatarsophalangeal joint with
1. Easley ME, Davis WH, Anderson RB. Intermediate to long-term follow-up of vitallium plate fixation. Foot Ankle Int. 1994;15:18-28.
medial approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int. 9. Smith RW, Katchis SD, Ayson LC. Outcomes in hallux rigidus patients treated
1999;220:147-52. nonoperatively: a long-term follow-up study. Foot Ankle Int. 2000;21:906-13.
2. Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthritis of the first metatar- 10. Coughlin MJ, Shurnas PJ. Hallux rigidus. Grading and long term results of
sophalangeal joint. J Bone Joint Surg Am. 1998;80:898-908. operative treatment. J Bone Joint Surg Am. 2003:85(11):2072-2088.
3. Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Joinnt 11. Coughlin MJ, Shurnas PJ. Soft tissue arthroplasty for hallux rigidus. Foot Ankle
Surg Am. 1988;70:400-6. Int. 2003:24(9)
4. Hamilton WG, O’Malley MJ, Thompson FM, Kovatis PE. Capsular interposition 12. Mroczek K, Miller S. Foot Ankle Int. 2003:24(7)
arthroplasty for severe hallux rigidus. Foot Ankle Int. 1997;18:68-70. 13. Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthro-
5. Moberg E. A simple operation for hallux rigidus. Clin Orhtop. 1979;142:55-6. plasy in hallux rigidus. Foot Ankle Int. 2001;22:462-470.
6. Thomas PJ, Smith RW. Proximal phalanx osteotomy for the surgical treatment of 14. Ghalambor N. Foot Ankle Int. 2002:23(2)
hallux rigidus. Foot Ankle Int. 1999;20:3-12. 15. Rahman H, Fagg P. J Bone Joint Surg (Br), 1993; 75-B
7. Townley C, Taranow W. A metallic hemiarthroplasty resurfacing prosthesis for 16. Fuhrmann RA, Wagner A. Foot Ankle Clin N Am, 2003(8)
the hallux metatarsophalangeal joint. Foot Ankle Int. 1994;15:575-80.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
107
SYM 07:Layout 1 1/12/07 11:40 AM Page 108

LATERAL ANKLE INSTABILITY: EVALUATION AND TREATMENT

Bruce Cohen, MD
SYMPOSIA FOOT/ANKLE

I. Definition/etiology of lateral ankle/hindfoot instability 1. Calcaneofibular ligament

a. What is it? a. Probably most important (Heilman et al)
i. Isolated tibio-talar instability 2. Talocalcaneal ligament
ii. Isolated subtalar instability 3. Extensor retinaculum
iii.Combined ankle/subtalar instability ii. Internal restraints
b. Functional vs. mechanical instability 1. Fibulotalocalcaneal ligament
i. Functional = symptoms without objective findings 2. Ligament of the anterior capsule of the posterior
1. more frequent facet joint
2. clinical diagnosis not radiographic 3. Cervical ligament
a. Runs obliquely from anterior calcaneus to the
II. Historical review – subtalar instability
superior talar neck
a. Rubin and Witten (1962)
4. Interosseous ligament
i. First to suggest clinical significance of subtalar insta-
a. Lies between the anterior and middle facets
bility
iii.Spring ligament may impart some medial stability
ii. Foot holding device to evaluate
iii.Varus stress tomograms IV. How to diagnose combined instability
iv. 27 patients tested, 17 with symptoms of instability – a. History
none found to have abnormal tomogram i. Acute inversion injury - often in association with later-
b. Laurin et al (1968) al ankle injury/peroneal injury
i. Cadaver ligament sectioning and stress tomograms ii. Recurrent – even with ADLs
ii. CF ligament important stabilizer 1. Eventually occurs with little sign of soft tissue
iii.Manual testing as good as a foot holding device injury
c. Chrisman and Snook (1969) 2. In younger individual r/o coalition
i. Recognized subtalar instability in combination with b. Symptoms
ankle instability (intraoperative determination) i. Foot rolls under the patient, particularly on uneven
ii. Modified Elmslie technique eliminated instability ground
d. Brantigan et al (1977) ii. During athletic activities when changing directions
i. Employed method of Rubbin and Witten and found 3 iii.Relatively benign actions like stepping on a pebble
patients with instability may induce
ii. Advocated stress tomograms iv. Rarely pain
1. If so, think of other associated entities (numerous)
III. Anatomy
a. OCD
a. Tibio-talar joint
b. Tendon pathology
c. DJD/impingement
d. Coalition
c. Clinical exam – compare to contralateral
i. Anterior drawer
1. Actually anteromedial rotatory maneuver
2. Very subjective
ii. Stress the foot into varus
1. Foot in dorsiflexion - assessing the integrity of the
i. Anterior talo-fibular ligament CF and TC ligaments
1. Lies within the capsular layers a. Look for subfibular “dimple”
2. Distinct structure arthroscopically 2. Subtalar instability - calcaneus tilts into varus while
ii. Calcaneofibular ligament talus remains stable within mortise
1. Crosses both ankle and subtalar joint 3. Occasional “click” or “clunk” may be perceived
2. Deep to peroneals 4. Difficult to differentiate ankle from subtalar insta-
3. Lies in line with the superior peroneal retinaculum bility
a. Combined instability = gap between lateral talar
process and distal fibula, dimple in skin
iii.Assess hindfoot alignment
1. Varus
2. Plantarflexed 1st ray
3. Use Coleman block test
iv. Always assess peroneal tendon
1. Subluxation
2. Dislocation
b. Subtalar joint stabilizers 3. Fullness
i. External restraints a. Split tears- brevis
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
108 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 109

b. Complete tears- longus i. Dorsiflexion 1st metatarsal

d. Radiographs ii. Dwyer Calcaneal
i. Plain views usually normal iii.Step-cut lateral calcaneal osteotomy
ii. Stress views of ankle 1. more powerful than dwyer
1. I don’t routinely obtain b. Nonanatomic ligament reconstruction restricting
2. In normal ankle – <12 degrees of tibiotalar tilt or subtalar motion (i.e. Chrisman-Snook)
<5 degrees from contralateral i. Will significantly limit inversion

SYMPOSIA FOOT/ANKLE
a. Controversial – what is normal? ii. Use when anticipate failure of other proce-
b. User dependent dures
c. Requires relaxation or anesthesia 1. Varus
3. Combined instability pattern? 2. Neuromuscular (flail ankle)
iii.Stress tomograms or Broden’s views of subtalar joint 3. Failed “local” procedures
1. Assess for angular instability – loss of facet paral- iii.Multiple bone tunnels
lelism 1. technically challenging
2. What is normal? How much stress applied? 2. improved with interference screw fixation
3. Refuted as a reasonable or valid study (Van v. Arthroscopic exploration in cases of intra-articular
Hellemondt et al, FAI ‘97) pain or pathology (i.e. OCD)
iv. Stress lateral inversion view vi. For combined patterns of instability
1. Difficult to obtain 1. Anatomic reconstruction?
2. Abnormal? = >10 mm of anterior translation of a. Modified Brostrom with imbrication of the
the posterior facet of the calcaneus relative to the extensor retinaculum (Gould modification)
talus (Harper, Kato) i. Identification and advancement of retinacu-
v. Fluoroscopy lum adequate for subtalar instability?
1. Probably reasonable if significant hypermobility b. Free graft repair of isolated injured structures
exists c. Triligamentous (Schon, Sammarco)
2. Dynamic evaluation 2. Nonanatomic reconstruction
vi. Arthrography a. Why would one consider performing a tendon
1. Myer (1988), Clanton (1989) augmentation or tendon “weave” nonanatomic
2. Leakage of dye signifying a lateral capsular/liga- technique?
mentous tear? i. Subtalar/combined instability
3. Invasive- increased morbidity – historical signifi- ii. Revision surgeries – failure of local “anatom-
cance? ic” repairs
vii. MRI iii.Severe varus hindfoot
1. Helpful in work-up of “painful” instability iv. Obesity
a. Assess for intra- and extra-articular abnormalities v. Heavy laborer
2. Assess for changes in the sinus tarsi vi. Flail or neurologically impaired ankle
a. Tears in the cervical or interosseous ligament vii. Peroneal dysfunction
b. Chronic inflammation/synovitis b. Numerous types described
i. Watson-Jones
V. Treatment
ii. Chrisman-Snook
a. Nonoperative
iii.Evans
i. 1st line of treatment
iv. Elmslie
ii. Proprioceptive training
c. Provide excellent lateral stability – tendon trans-
iii.Peroneal strengthening, Achilles stretching
fers described often cross the subtalar joint twice
iv. Bracing
and perpendicular to the axis
v. Orthosis
d. Often too constraining for normal foot function
1. Semi-rigid
– overtighten the subtalar joint and decrease
2. Arch support, heel cupping, lateral heel wedge
ankle ROM
vi. Shoewear modifications
e. Accelerate hindfoot degenerative changes?
1. High-top
f. Modified Brostrom-Split Evans
2. Lateral flare
i. Popularized by Anderson/Davis- Charlotte
b. Operative
ii. Augments primary repair with a slip of the
i. Indications – in general
peroneus brevis- anterior 1/3rd
1. Failure of nonoperative care
1. Rationale- anecdotal experience with the
2. Inability to brace (skin/work/dancer)
classic modified Brostrom was that it does
3. Recurrent sprains with daily activities
not hold up well over time and is insuffi-
ii. Must consider that any procedure that stabilizes the
cient is large athletes, heavy laborers and
subtalar joint will also reduce the joint’s ability to
obese
compensate to uneven terrain
iii.Studies showed no overtightening or loss of
iii.Need to consider whether there is isolated tibio-talar
peroneal strength (Girard)
or combined subtalar-ankle instability
a. FAI, 1999
iv. Consider mechanical axis
b. AOFAS score 98.2
1. Varus should be recognized and corrected to avoid
2. Add a Dwyer calcaneal osteotomy or dorsi-
risk of recurrence
flexion 1st metatarsal osteotomy for cavo-
2. Options if varus
varus foot
a. Osteotomy

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
109
SYM 07:Layout 1 1/12/07 11:40 AM Page 110

1. Gracilis autograft
2. 13 degrees to 3 degrees talar tilt postop
3. 10-5 mm ant drawer postop
vii. Other Authors
1. Maffuli, Foot and Ankle Clinics, Sept, 2006
a. Semitendinosus allograft
2. Younger, Foot and Ankle Clinics, Sept 2006
SYMPOSIA FOOT/ANKLE

a. Gracilis allograft
VIII. Author’s treatment algorithm
a. Modified Brostrum-Gould
i. Thin patients
VI. Surgical results ii. Dancers
a. Complications iii.Low-activity levels
i. Sural neuritis/neuroma iv. Skilled positions- football
ii. Overtightening –loss of function or late arthritis b. Modified Brostrum-Evans
iii.Recurrence – especially if hindfoot varus was not i. Heavy laborers
addressed ii. Workers compensation patients
iv. Residual pain/synovitis – may necessitate subtalar iii.Obese patients
arthrodesis iv. Football linemen
c. Modified Colville/Coughlin
VII. Revision surgery for failed reconstruction i. Revisions
a. Modified Colville/Coughlin ii. Poor collagen
i. Gracilis or semi-tendinosis allograft 1. multiple joint instability
ii. “Anatomic” Chrisman-Snook 2. collagen vascular disease
iii.Biotenodesis screws to anchor in talus and calcaneus iii.Tenodesis vs anatomic repair
iv. Allograft limbs in line with path of ATFL and CFL 1. Van Djik- FAI 2001
v. Correct varus, if present a. Multicenter, retrospective
1. Dwyer vs. 1st metatarsal b. Better satisfaction with anatomic vs tenodesis
a. 2 separate incisions recommended for Dwyer c. Better functional results with anatomic
and lateral ankle (Hammit et al, Techniques in i. Talar tilt
Foot and Ankle Surgery) ii. Anterior drawer
vi. Coughlin, FAI 2004, April 231-41 iii.Degenerative subtalar changes

REFERENCES 8. Kato T: The diagnosis and treatment of instability of the subtalar joint. J Bone
1. Brantigan JW, Pedegana LR, Lippert FG: Instability of the subtalar joint: Joint Surg Br 1995: 77B:400.
Diagnosis by stress tomography in three cases. J Bone Joint Surg 59A: 321-324, 9. Laurin CA, Ouellett R, St-Jacques R: Talar and subtalar tilt: An experimental
1977. investigation. Can J Surg 1968; 11:270.
2. Clanton T: Instability of the subtalar joint. Orthop Clin North Am 1989; 10. Meyer M, Lazier R: Post-traumatic sinus tarsi syndrome. Acta Orthop Scand
20:583. 1977; 48:121.
3. Coughlin MJ, Schenck RC: Lateral ankle reconstruction. FAI 22 (3) 256-8, 2001. 11. Pisani G: Chronic laxity of the subtalar joint. Orthopedics 1996; 19:431.
4. Coughlin MJ, Schenck RC, Grebing BR, et al: Comprehensive reconstruction of 12. Schon LC, Clanton TO, Baxter DE: Reconstruction for subtalar instability: A
the lateral ankle for chronic instability using a free gracilis graft. FAI 25 (4) 231- review. Foot Ankle 1991; 14:319.
41, 2004. 13. Van Hellemondt FJ, Louwerens JWK, Sijbrandij ES, VanGils APG: Stress radiogra-
5. Girard P, Anderson, R, Davis W, et al: Clinical evaluation of the modified phy and stress examination of the talocrural and subtalar joint on helical com-
Brostrom-Evans procedure to restore ankle stability. FAI 20: 246-52, 1999. puted tomography. Foot Ankle Int 1997; 18:482.
6. Harper MC: The lateral ligamentous support of the subtalar joint. Foot Ankle 14. Krips R, van Dijk CN, Halasi PT et al: Long-term outcome of anatomical recon-
1991; 11:354. struction versus tenodesis for the treatment of chronic anterolateral instability of
7. Heilman A, Braly G, Bishop J, et al: An anatomic study of subtalar instability. the ankle joint. Foot Ankle Int. 2001, 22(5), 415-21.
Foot Ankle 1990; 10:224.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
110 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 111

◆ CARTILAGE RECONSTRUCTION

SYMPOSIA FOOT/ANKLE
OF THE ANKLE JOINT (F)
Moderator: Loretta B. Chou, MD, Stanford, CA (n)
The treatment of cartilage injury and disorders is one of the greatest challenges facing
orthopedic surgeons treating the ankle joint. According to a 2005 online survey, the
American Orthopaedic Foot and Ankle Society (AOFAS) members consider cartilage
reconstruction research to be the most important area that needs support. There are many
treatment options. Non-operative treatment has a high failure rate, 55% of patients.
Arthroscopic debridement, subchondral drilling and microfracture can have good success in
appropriate candidates. Therefore, alternative treatments are needed and are currently being
investigated. The purpose of this symposium is to present: debridement, microfracture,
autologous chondrocyte implantation (ACI), osteochondral autograft transfer system
(OATS), autologous chondrocyte implantation (ACI), matrix assisted chondrocyte
implantation (MACI), and salvage procedures of allograft arthroplasty, arthrodesis and
arthroplasty.

I. Basic Science of Articular Cartilage of the Ankle Joint

Jason L. Dragoo, MD, Palo Alto, CA (n)

II. Arthroscopy, Debridement, Microfracture and Autologous Chondrocyte Implantation

(ACI)
Jeffrey A. Mann, MD, Oakland, CA (n)

III. Osteochondral Autograft Transfer System (OATS)

Pierce E. Scranton, Jr, MD, Kirkland, WA (c - Arthrex Corp.)

IV. Matrix Assisted Chondrocyte Implantation (MACI)

Martin R. Sullivan, MD, Sydney, Australia (n)

V. Salvage with Allograft Arthroplasty, Arthrodesis and Arthroplasty

Cliff L. Jeng, MD, Baltimore, MD (n)

VI. Panel Discussion, Questions and Answers

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
111
SYM 07:Layout 1 1/12/07 11:40 AM Page 112

BASIC SCIENCE OF ARTICULAR CARTILAGE OF THE

ANKLE JOINT
Jason L. Dragoo, MD
SYMPOSIA FOOT/ANKLE

I. The composition and structure of articular cartilage deter- i. Compressive properties

mines function ii. Tensile properties
a. Proteoglycans iii.Sheer properties
i. Fixed charge density (FCD)
III. Effect of abnormal mechanical loading
ii. Interstitial water
a. Malalignment secondary to:
b. Collagen ultrastructure
i. ligamentous injury
i. Lattice structure
ii. fracture
ii. Boundry structures-tidemark, lamina splendins
iii.developmental anomaly
iii.Water flow _ Friction
b. Articular cartilage injury
iv. Force dissipation
c. Effect of cartilage injury IV.Treatment of injury
i. Loss of proteoglycans/ FCD a. Must recreate the structure and function of articular carti-
ii. Disruption of ultrastructure lage
iii.Loss of function b. Must recreate normal tissue biomechanics
c. Current treatments sub-optimal
II. Biomechanics of the articular cartilage
a. Normal tissue biomechanics

References 2. Mow VC, Wang CC. Bioengineering Considerations for Tissue Engineering of
1. Basic Orthopaedic Biomechanics & Mechano-Biology. 3rd ed. Mow, Van C., Articular Cartilage. Clin Orthop Relat Res. Oct, 1999.
Huiskes, Rik. ISBN: 0781739330 Philadelphia : Lippincott Williams & Wilkins,
2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
112 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 113

ARTHROSCOPY, DEBRIDEMENT, MICROFRACTURE AND

AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) FOR
TREATMENT OF OSTEOCHONDRAL LESIONS OF THE TALUS

SYMPOSIA FOOT/ANKLE
Jeffrey A. Mann, MD, Oakland, California

I. Introduction IV.Treatment of OLT’s

A. Definition – Osteochondral lesion of the talus A. Non–operative treatment of OLT’s: Indications
• Focal cartilage damage of the talus, acute or chronic, • Stage 0: marrow edema – always try non-operative
with or without bony involvement treatment
B. Terminology • Stage 1: articular cartilage only – non-operative treat-
• Osteochondral lesions of the talus: OLT (the most ment if acute onset
accurate term) • Stage 2: cartilage, bone – non-operative treatment if
• Also referred to as: Osteochondral defects (OCD’s), acute onset
osteochondritis dissecans, osteochondral fracture, • Stage 3: Non-displaced OLT’s in the acute setting
transchondral fracture — If small (< 5 mm), consider non-operative
— If larger lesion, I recommend pinning
II. Etiology - mechanism of injury
• Stage 5: Subchondral cyst - non-operative treatment if
Trauma
acute exacerbation
• Single twisting injury – causes osteochondral fracture
B. Non-operative Treatment:
or impaction of anterolateral talar dome
• NWB cast 4 weeks, WB cast for 4 weeks or until symp-
• Repetitive twisting injuries – leads to chronic antero-
toms resolve
lateral lesions
• Resume non-impact activities gradually
• Repetitive microtrauma – may be a factor in postero-
C. Results of non-operative treatment (Tol et al)
medial lesions
• Meta-analysis of 201 patients, 14 studies, Grade 1, 2
Ischemia
and medial grade 3
• Likely plays a role in developing posteromedial lesion
• 45% successful nonsurgical treatment overall
• Predisposition for talar dome ischemia due to abnor-
• Chronic lesions had 56% success rate (only 3 studies)
mal vasculature
D. Operative Indications
• Congenital or developmental ossification defect
1. Failure of non-operative treatment
Location
2. Chronic cartilage or cartilage/bone lesions
• Postero-medial lesions (60%) – most have bony
3. Large, acute non-displaced lesion
involvement; cup- shaped
4. Displaced fragment
• Antero-lateral lesions (40%) – many purely cartilagi-
5. Subchondral cyst
nous or with minimal bone involvement; wafer-
6. Performing ankle ligament reconstruction or other
shaped.
foot/ankle reconstruction
• Lateral lesions may have associated AJ instability
E. Surgical Technique: Debridement and Drilling
III. Classification systems 1. Thorough arthroscopic evaluation
A. Berndt and Harty classification of OLT (modified) 2. Pin viable osteochondral fragments larger than 5-
• Stage 0 – Marrow edema on MRI 6mm with bioabsorbable device (may need arthroto-
• Stage 1 – area of compressed subchondral bone my/osteotomy)
• Stage 2 – partially attached osteochondral fragment 3. Remove unsalvageable fragments of bone and carti-
(or subchondral cyst) lage
• Stage 3 – completely detached but nondisplaced frag- 4. Debride edges of lesion to achieve stable rim of carti-
ment lage
• Stage 4 – completely detached and displaced osteo- 5. Drill or microfracture base of lesion to create vascular
chondral fragment access channels
B. MRI classification (Hepple) 6. Marrow elements migrate into site of injury to pro-
• Stage 1 – Articular cartilage damage only duce firbrocartilage
• Stage 2a – Cartilage injury, underlying fracture, bone F. Postoperative Protocol: Debridement/drilling- Short peri-
edema od of non-WB, 5 - 7 days, CAM walker for 2-3 wks, start
• Stage 2b – Stage 2a with no bone edema ROM/strengthening. If fragment has been repaired or
• Stage 3 – Detached, undisplaced fragment osteotomy performed, 4-6 wks non-WB
• Stage 4 – Detached, displaced fragment
V. Results of Treatment
• Stage 5 – Subchondral cyst formation
A. Debridement and Drilling – Ferkel- 72% good/exc results
C. Articular Cartilage Classification (Cheng, Ferkel)
in 64 patients
• Grade A - Smooth, intact but soft or ballotable
• Average f/u 71 months, avg age 32, avg AOFAS 84
• Grade B - Rough surface
B. Results of operative treatment - Tol et al.
• Grade C - Fibrillations/fissures
• Meta-analysis of 381 patients, 18 studies
• Grade D - Flap present or bone exposed
• Excision alone, 39 patients: 38% successful
• Grade E - Loose, undisplaced fragment
• Open excision and curettage: 63% successful
• Grade F - Displaced fragment
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
113
SYM 07:Layout 1 1/12/07 11:40 AM Page 114

• Arthroscopic excision and curettage: 86% successful c. 11 good/exc, 3 poor/fair

• Excision, curettage, drilling: 88% successful 2. Giannini (JBJS 2005)
C. Results of operative treatment for cystic (type 5) lesions a. Review of 80 pt’s treated for OLT’s
• Robinson (JBJS-B, 2003): 53% poor results in cystic b. 34 patients had ACI
lesions c. AOFAS 90.5 at 12 mos, 93.2 at 4 yrs (all 80 pt’s)
• Kolker (JBJS-B, 2004): 54% dissatisfied d. MRI demonstrated >75% repair of defect depth
D. Debridement and Drilling: disadvantages e. Histological exam showed “primitive” organization
SYMPOSIA FOOT/ANKLE

• Drilling forms fibrocartilage, which is not normal car- of cartilage

tilage 3. Whittaker (JBJS-B 2005)
• Some studies show fibrocartilage deteriorates over a. 9 of 10 good/excellent results at 23 mos after ACI
time, with x-ray arthrosis at long-term follow-up b. 2nd-look arthroscopy at 1 year showed filled
• High failure rate when subchondral bone is involved defects
c. Biopsies showed mainly fibrocartilage, some hya-
ACI PROCEDURE
line
A. General comments
d. 7 had donor site (knee) morbidity
1. Autologous chondrocyte implantation (ACI)
4. ACI vs OATS – Horas (JBJS 2003)
2. Normal cartilage is biopsied from the knee, grown in
a. prospective study, 40 pt’s, 2 yr f/u, medial femoral
the lab and reimplanted into cartilage defect
condyle
3. Popularized by Lars Peterson in early 90’s
b. Half had carticel procedure, half OATS procedure
4. Knee studies: 85% good/exc at 7.4 years
c. Clinical results equal at 2 years, slower recovery in
5. Most biopsy specimens show “hyaline characteristics”
ACI
B. ACI Procedure in the ankle
d. Biopsy specimens showed mainly fibrocartilage in
1. Technically challenging
ACI, with few areas of hyaline-like cartilage
2. Must have a clean margin to sew periosteal flap
e. Biopsy showed normal cartilage in OATS procedure
3. Limited access to area of damage, even with tibial
5. ACI vs mosaicplasty – Bentley (JBJS-B 2003)
osteotomy
a. Prospective study, 100 pts, 19 mo f/u
4. If subchondral cyst is deeper than 3-4 mm, it must be
b. 88% exc/good results after ACI
bone-grafted and layered with periosteum, then carti-
c. 69% exc/good results after mosaicplasty
lage cells placed on top
d. 2nd-look arthroscopy at 1 year;
C. ACI Literature
i. 82% exc/good repairs after ACI
1. Peterson (IFFAS 2002)
ii. 34% exc/good repairs after mosaicplasty
a. 14 patients, avg 33 mo f/u
b. Avg size 1.7cm2

REFERENCES 7. Hepple S et al. Osteochondral Lesions of the Talus: a revised classification. Foot
1. Bentley G et al. A prospective, randomized comparison of autologous chondro- Ankle Int. 1999;20:789-793.
cyte implantation verses mosaicplasty for osteochondral defects in the knee. J 8. Horas U et al. Autologous chondrocyte implantation and osteochondral cylinder
Bone Joing Surg Br. 2003;85-B:223-230. transplantation in cartilage repair of the knee joint. J Bone Joint Surg Am.
2. Brittberg M. Autologous chondrocyte transplantation. Clin Orthop. 2003;85-A:185-92.
1999;367S:S147-55. 9. Koh JL et al. The effect of graft height mismatch on contact pressure following
3. Brittberg M et al. Treatment of deep cartilage defects in the knee with autologous osteochondral grafting. Am J Sports Med. 2004;32:317-320.
chondrocyte transplantation. New England J Med. 1994;76-A:889-895. 10. Schachter AK et al. Osteochondral Lesions of the Talus. J Am Aca Orthop Surg
4. Giannini S et al. Autologous chondrocyte transplantation in osteochondral 2005;13:152-158.
lesions of the ankle joint. Foot Ankle Int. 2001;22:513-7. 11. Scranton PE et al. Outocme of osteochondral autograft transplantation for type-
5. Giannini S et al. Surgical treatment of osteochondral lesions of the talus in V cystic osteochondral lesions of the talus. J Bone Joing Surg Br. 2006;88-B:614-
young active patients. J Bone Joing Surg Am. 2005;87-A; Supp 2:28-41. 619.

6. Gross AE et al. Osteochondral defects of the talus treated with fresh osteochon- 12. Tol JL et al. Treatment strategies in osteochondral defects of the talar dome: a
dral allograft transplantation. Foot Ankle Int. 2001;22:385-91. systematic review. Foot Ankle Int. 2000;21:119-126.
13. Whittaker JP et al. Early results of autologous chondrocyte implantation in the
talus. J Bone Joing Surg Br. 2005;87-B:179-83.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
114 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 115

CARTILAGE RECONSTRUCTION OF THE ANKLE JOINT

Pierce E. Scranton, Jr., MD

1. Etiology: Grade III Grade IV

Trauma

SYMPOSIA FOOT/ANKLE
Edema
Articular surface defects
Synovial fluid intrusion
Vascular compromise
Transchondral fracture Transchondral fracture
2. Factors in Resurfacing Strategy
(intact) (displaced)
Lesion size (< 6.0mm, >6.0mm)
Which bone (talus, tibia) Grade V
Location in the joint (medial, lateral, anterior, posterior)
3. Treatment Options
a. Drilling or microfracture
b. Retrograde drilling or grafting
c. Mosiacplasty
d. Carticel Cystic blowout in Grade II, III or IV
e. Osteochondral Autograft (allograft) Transplant 9. TREATMENT OPTIONS
(O.A.T.S.) A. Acute
4. Articular Donor Options 1. Cast immobilization for three to six weeks.
Open autograft 2. Physical therapy for ankle rehab
Arthroscopic harvest, autograft 3. Follow the patient for symptoms for at least three to
“Nested” autografts six months.
Allograft cores B. Chronic
En bloc allografts 1. Grade II-IV
Macro allografts a. Open or arthroscopic debridement or drilling 0.62
mm K wire
5. Special considerations - talus. b. Fixation with: biodegradable pegs, Herbert screws,
The Berndt and Harty classification of 1959 has stood the retrograde fixation
test of time both as to treatment and probable etiology of 2. Grade V
osteochondral lesions of the talus. It was based upon plain a. Osteochondral grafts (OATS, CORE, mosaicplasty)
roentgenograms, however, and with the advent of MRI and ipsilateral knee, open or arthroscopic harvest.
CT, large cystic lesions are seen present in all classifications,
and these require different treatment. This portion of the 10. SURGICAL TECHNIQUE CONSIDERATIONS
symposium will deal with the management of these diffi- A. Anteromedial Talar Lesions
cult cystic lesions of the talus. 1. Arthroscopy if necessary
2.Arthrotomy, establish lesion size
6. CLINICAL PRESENTATION 3. Core-out or drill the lesion to at least 10 mm depth
A. History of trauma (previous sprain or fracture) 4. Compact the base and measure depth
B. Sudden sharp pain with loaded motion 5. Harvest the donor graft from the knee
C. Point tenderness on the medial or lateral corner of the 6. Insert the donor graft and close
talus B. Posterolateral Lesions
D. Slight synovitis or effusion 1. Arthrotomy and release the ATF
E. Recurrent painful clicking or catching 2. Sublux the talus anteriorly
7. RADIOGRAPHIC STUDIES 3. Establish lesion size
A. Plain roentgenogram. 4. Core-out or drill the lesion to at least 10 mm depth
B. AP, mortise, lateral, maximum dorsi- and plantar flexion 5. Compact the base and measure depth
mortise views. 6. Harvest the donor graft from the knee
C. Technetium 99 bone scan. 7. Insert the donor graft and close
D. Computed axial tomography (CAT scan) 11. SURGICAL TECHNIQUE (OATS for lesions 8 – 20mm)
E. Magnetic resonance imaging (MRI) A. Posteromedial Talar Lesions:
8. RADIOGRAPHIC CLASSIFICATION 1. Arthroscopy if necessary
2. Incision exposes the anterior and posterior
Grade I Grade II malleolar/joint borders
3. Pre-drill the malleolus before osteotomy
4. Use C-arm or fluoroscopy to ensure the osteotomy is
at the appropriate level
5. Start the osteotomy with an oscillating saw and com-
plete it with an osteotomy
Articular scuffing Articular defect 6. Arthrotomy, establish lesion size
7. Core-out or drill the lesion to at least 10 mm depth

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
115
SYM 07:Layout 1 1/12/07 11:40 AM Page 116

8. Compact the base and measure depth 4. Three weeks sports-specific rehabilitation
9. Harvest the donor graft from the knee C. Grade V (OATS)
10.Insert the donor graft and close 1. Three weeks nonweightbearing (immobile)
11.Reduce the malleolar osteotomy and close 2. Three weeks nonweightbearing (mobile)
3. Three weeks weightbearing (immobile)
12. SURGICAL AFTER CARE
4. Three weeks non-impact rehabilitation
A. Grade I - III (Drilling or debridement)
5. Three weeks sports-specific rehabilitation
1. Three weeks nonweightbearing (no immobilization)
SYMPOSIA FOOT/ANKLE

2. Three weeks non-impact rehabilitation (swimming, 13. Results of OATS, 50 cases, 2-6 years follow up:
bicycling, etc..) A. 32/50 had one or more previously failed surgeries prior
3. Three weeks accelerated activity or sports-specific reha- to OATS
bilitation (running, cutting, etc…) B. 45/50 or 90% good to excellent results
B. Grade III - IV (Internal Fixation) C. Average Karlsson-Peterson ankle score was 76
1. Three weeks nonweightbearing (immobile) D. 15 required either screw removal or second looks for scar
2. Three weeks nonweightbearing (mobile) debridement
3. Three weeks graduated non-impact rehabilitation E. 2 failed and required an ankle arthrodesis

FURTHER READING 5. Ewing JW: Arthroscopic Management of Transchondral Talar-Dome Fractures

1. Alexander AH, Lichtman, DN: Surgical treatment of Transchondral Talar-Dome (Osteochondritis Dessicans) and Anterior Impingement Lesions of the Ankle
Fractures (Osteochondritis Dessicans). Long-term follow-up. J. Bone & Joint Surg Joint. Clin Sports Med., 10:677-87, 1991.
62A:646-52, 1980. 6. Ferkel RD, Scranton PE: Arthroscopy of the ankle and foot. J Bone Joint Surg,
2. Al-Shaikh RA, Chou LB, Mann JA, et al.; Autologous osteochondral grafting for 75A:1233-42, 1993.
talar cartilage defects. Foot Ankle Int, May 2002, 23(5):381-9 7. Scranton PE, McDermott JE: Type V Osteochondral Lesions of the Talus with
3. Berndt AL, Hardy M: Transchondral Fractures of the Talus. J Bone Joint Surg Ipsilateral Knee Osteochondral Autografts. Foot Ankle Int, 22:380-384, 2001.
41A:988-1020, 1959. 8. Scranton, PE, Frey, CC, Feder, KS: Outcome of osteochondral autograft transplan-
4. Scranton, P.E. Contributing author, text: Foot and Ankle Clinics, “Osteochondral tation for type V cystic osteochondral lesions of the talus. J. Bone Joint Surg.
autologous transfer system”. Consulting Editor Mark Myerson; Guest Editor 88B: 614-619, 2006.
Mark E. Easley, MD; W.B. Saunders Company Publisher, 8(2): 275-290, June
2003

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
116 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 117

MATRIX-INDUCED AUTOLOGOUS CHONDROCYTE

IMPLANTATION (MACI) OF THE TALUS
Martin Sullivan, MD, Eric Giza, MD

SYMPOSIA FOOT/ANKLE
Osteochondral Lesions of the Talus MACI Technology
Chronic sprains or acute injury can lead to damage of the artic- • Current technology is MACI® (Genzyme/Verigen)
ular surface of the talus. Sprains are the most common injury • Porcine type I/III collagen membrane is seeded with chon-
to the ankle in sport, and it is estimated that injuries to the talus drocytes
occur in 6.5% of all ankle sprains [1, 2].
MACI Investigation
Patients with cartilage damage to the talus will complain of • 2 year, prospective, independently funded study
swelling and medial or lateral ankle pain associated with activ- • Total of 10 patients with isolated talar dome lesions and
ity. Report of an ankle sprain that has failed to completely heal failed attempt at curettage/microfracture
by 8 weeks should raise suspicion of a talus cartilage injury. The • Pre-op Scoring: AOFAS Hindfoot Score, SF-36, MRI with
patient may have a normal exam without evidence of instabili- ICRS Scoring
ty; however, direct pressure over the talus with the ankle in plan- • Intra-op Grading and lesion size
tarflexion will elicit tenderness. Plain radiographs of the ankle • Post-op Scoring at 1 year & 2 years
can only identify 50-66% of lesions [3], and the only evidence
Sydney 2 Year MACI Results
may be an inconsistency in the trabecular bone of the talus. MRI
• Results for 10 Patients Available at 2 Years
is superior to radiographs to determine the location and size of
• Average 1.7 prior procedures
the lesion. Bone edema and potential stability of the fragment
• Average time of injury or symptom onset to MACI = 4.6
can be determined on MRI which is useful for operative plan-
years
ning [4].
• Lesion Size: 1.34 ± 0.34cm in length, 1.02 ± 0.35cm in
The cartilage of the talus differs in composition and thickness width
than that of the knee [5]. Robinson et al., demonstrated that • Average surface area of 1.39 ± 0.66cm2
traumatic lesions occur on both the lateral and medial aspects • AOFAS hindfoot scores (1 year)
of the talar dome [6]. At arthroscopy, 20 of 65 patients had lat- — Preoperative = 67.5 ± 13.8 (range 42-76)
eral dome injuries. The lateral injuries were more often delami- — Postoperative = 77.0 ± 11.4 (range 46-87)
nation type injuries and the average time to presentation was — Significant improvement (p<0.05)
1.5 years. Medial lesions occurred in 45 of 65 patients, 35 of the • SF36 Results (2 years): Significant improvement in:
45 were associated with a single traumatic event, and the aver- — Bodily Pain (p=0.011)
age time to presentation was 3 years. — Physical Functioning (p=0.011)
— No significant difference in results between 1 and 2 years
Ankle arthroscopy is recommended for cases failing conserva-
• SF 36 Data Question (1 year)
tive measures, and is an effective means for diagnosis and treat-
— Compared to one year ago, how would you rate your
ment of lesions of the talus, with up to 85% of patients improv-
health now?
ing after arthroscopic drilling or curettage [7, 8]. Takao et al.
— Significant difference (P = 0.007)
have shown improved outcomes if the damaged cartilage is
• 10 of 10 would have procedure again
removed and microfracture is performed compared to indirect,
• No complications yet to report
subchondral drilling [9]. Larger lesions that fail to improve four
months after arthroscopy should be considered for osteochon- MACI Summary
dral grafting or autologous chondrocyte implantation (ACI). • Represents the “second generation of ACI”
Osteochondral grafting of defects have yielded 91-94% good to • Good alternative for patients who fail microfracture and/or
excellent results [10, 11]; however, limited incision or arthro- curretage
scopic ACI procedures will likely become the standard of care • Medial malleolar osteotomy not necessary
for these lesions [12]. Recently, Baums and colleagues reported • It is not a first line treatment option but rather a “salvage”
encouraging results in 12 patients at a mean of 63 months fol- procedure
low up [13]. Whittaker also described excellent results in 10 • Cells are derived from the ankle joint and cartilage removed
patients at an average of 23 months [14]. We report excellent at time of arthroscopic surgery can be utilized as source of
results of a 2 year, prospective study of ACI for talar dome chondrocytes
lesions using a type I/III collagen membrane. • Encouraging clinical results with two year data particularly
in terms of pain relief and function
Discussion Outline • Long term data needed to elucidate quality of repair tissue
Talus Cartilage Treatment Options for MACI
• Large >1cm delaminating lesions may not respond well to
microfracture and outcome less reliable
REFERENCES 3. Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of
1. Mandelbaum B, Gerhardt M, Peterson L. Autologous Chondrocyte Implantation the talus. American Journal of Sports Medicine. 1993;21(1):13-19.
of the Talus. Arthroscopy. 2003;18(10 (December, Suppl 1)):129-137. 4. Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective
2. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The study on diagnostic strategies in osteochondral lesions of the talus. Is MRI supe-
prevention of ankle sprains in sports. A systematic review of the literature. Am J rior to helical CT? Journal of Bone & Joint Surgery British Volume.
of Sports Med. 1999;27(6):753-760. 2005;87(1):41-46.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
117
SYM 07:Layout 1 1/12/07 11:40 AM Page 118

5. Sugimoto K, Takakura Y, Tohno Y, Kumai T, Kawate K, Kadono K. Cartilage thick- 10. Gautier E, Kolker D, Jakob RP. Treatment of cartilage defects of the talus by autol-
ness of the talar dome. Arthroscopy. 2005;21(4):401-404. ogous osteochondral grafts. Journal of Bone & Joint Surgery British Volume.
6. Robinson DE, Winson IG, Harries WJ, Kelly AJ. Arthroscopic treatment of osteo- 2002;84(2):237-244.
chondral lesions of the talus.[see comment]. Journal of Bone & Joint Surgery 11. Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of
British Volume. 2003;85(7):989-993. full-thickness defects of weight-bearing joints: ten years of experimental and clin-
7. Schuman L, Struijs P, Dijk Cv. Arthrosocpic treatment for osteochondral defects ical experience. Journal of Bone & Joint Surgery American Volume. 2003;2:25-32.
of the talus: Results at followup at 2 to 11 years. J Bone Joint Surg Br. 12. Koulalis D, Schultz W, Heydon M. Autologous Chondrocyte Transplantation for
2002;84B(3):364-368. Osteochondritis Dessicans of the Talus. Clin Orthop Rel Res. 2002;395:186-192.
SYMPOSIA FOOT/ANKLE

8. Giannini S, Buda R, Faldini C, et al. Surgical treatment of osteochondral lesions 13. Baums MH, Heidrich G, Schultz W, Steckel H, Kahl E, Klinger HM. Autologous
of the talus in young active patients. Journal of Bone & Joint Surgery American chondrocyte transplantation for treating cartilage defects of the talus. Journal of
Volume. 2005;2:28-41. Bone & Joint Surgery American Volume. 2006;88(2):303-308.
9. Takao M, Uchio Y, Kakimaru H, Kumahashi N, Ochi M. Arthroscopic drilling 14. Whittaker JP, Smith G, Makwana N, et al. Early results of autologous chondrocyte
with debridement of remaining cartilage for osteochondral lesions of the talar implantation in the talus.[erratum appears in J Bone Joint Surg Br. 2005
dome in unstable ankles. American Journal of Sports Medicine. 2004;32(2):332- Jun;87(6):886]. Journal of Bone & Joint Surgery British Volume. 2005;87(2):179-
336. 183.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
118 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 119

OSTEOCHONDRAL TOTAL ANKLE ALLOGRAFT

TRANSPLANTATION, PROSTHETIC TOTAL ANKLE
REPLACEMENT, AND ANKLE ARTHRODESIS

SYMPOSIA FOOT/ANKLE
Clifford L. Jeng, MD

I. Osteochondral total ankle allograft transplantation 2. Jeng and Myerson: failures due to 1) high body-mass
A. Rationale behind ankle transplant index 2) young age 3) pre-operative varus/valgus
1. To maximize joint function. malalignment.
2. Provide a biologic solution for resurfacing of the 3. Is the ankle truly immune-privileged or should we be
ankle. blood and tissue type matching as well as using post-
3. Avoid complications of fusion including non- operative immunosuppression for these transplants?
union/malunion.
II. Total ankle replacement (TAR)
4. To avoid long term morbidity associated with ankle
A. Obstacles to successful TAR
fusion.
1. Anterior midline incision difficult to heal (angiosome
B. How does it work?
theory)
1. Fresh osteochondral allografts are a composite of dead
2. Poor bone support
bone and viable cartilage.
3. Ankle joint reactive forces up to 5x body weight.
2. The dead bone portion of the osteochondral allograft
4. Small contact surface area (1/3 of hip or knee)
heals to the host bone similar to fresh frozen structur-
B. Second generation TAR improvements over 1st genera-
al allografts as described by Myerson (JBJS 87:113-120,
tion implants
2005) .
1. Uncemented
3. Williams showed that 98% of chondrocytes from
2. Minimal bone resection
human femoral osteochondral plugs can survive cold
3. Less constrained
storage in culture media.
4. Increased implant surface area
4. As far as the surrounding cartilage matrix, Williams
5. Improved alignment / cutting jigs
found that at 28 days of cold storage, there was no
6. Decreased load transfer to prosthesis-bone interface
difference in the indentation stiffness or compressive
C. Long-term survival of modern two-component design
modulus.
1. Knecht – 132 Agilitiy TAR followed for 9 years; 89%
C. Surgical technique
survival rate
1. Cutting jig and alignment guide from the total ankle
D. Long-term survival of three-component designs
instruments is used to remove 6-12 mm of bone from
1. San Giovanni – 28 Buechel-Pappas TAR in rheuma-
distal tibia and talar dome.
toids followed for 8.3 years; 89% success rate.
2. The same size cutting jig is affixed to the tibial allo-
2. Anderson – 51 STAR followed for 52 months; 76%
graft; the thickness of the cut is matched to the
survival rate.
amount resected from host.
3. Wood – 200 STAR 93% cumulative survival rate at 5
3. The talar allograft is cut to match the thickness of
years.
resected talus.
4. The allograft is inserted into the host ankle and then III. Ankle arthrodesis – “Gold Standard”
put through a range of motion to “seat” or position A. Different surgical techniques available
the transplant. 1. Approach: trans-fibular, mini-arthrotomy, or arthro-
5. The tibial side is fixed with two headless compression scopic
screws. The talar side is fixed with two bioabsorbable 2. Joint preparation: flat-cuts or feathered articular sur-
pins. faces
D. Clinical results of fresh osteochondral ankle transplant 3. Two or three-screw configuration
1. Brage – 16 patients followed for 62 months; 87% B. Success rates of open ankle arthrodesis versus arthroscop-
allograft survival ic ankle fusion comparable
2. Kim – 7 transplants followed for 148 months; 58% 1. Open arthrodesis fusion rates reported between 65-
survival rate. 95%.
3. Tontz – 12 patients followed 21 months; 92% survival 2. Arthroscopic fusion rates reported between 74-97%.
rate. C. Nearly all patients will develop hindfoot/midfoot/1st
4. Meehan – 11 patients followed for 31 months; 73% MTP arthritis if followed out long enough. No increased
survival rate. incidence of knee DJD.
5. Vora – 10 patients followed for 12 months; 50% sur- D. Risk factors for non-union
vival rate. 1. Smoking
6. Jeng, Myerson (2006) – 29 patients followed for 24 2. Avascular necrosis
months; 52% survival rate; only 31% survival includ- 3. Infection
ing radiographic failures. 4. Bone loss
E. Risk factors for failure and controversies 5. Revision procedures
1. Bugbee and Brage: failures due to 1) size mismatch E. Function following ankle arthrodesis
between graft and host and 2) allograft pieces being
cut too thin.
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
119
SYM 07:Layout 1 1/12/07 11:40 AM Page 120

1. Thomas - gait analysis shows significant difference in 3. Coester showed that nearly all patients had either
cadence and stride-length compared to matched con- hindfoot, midfoot, or forefoot arthritis at 22 years fol-
trols. lowing ankle fusion.
2. Muir - 79% difficulty with unlevel ground, 75% diffi-
culty with stairs, 64% aching with prolonged activity.
SYMPOSIA FOOT/ANKLE

REFERENCES 2. San Giovanni T, Keblish D, Thomas W, Wilson M. Eight-year results of a mini-

Ankle transplant mally constrained total ankle arthroplasty. Foot Ankle Int 27:418-426, 2006.

1. Williams SK, Amiel D, Ball ST, Allen RT, Wong VW, Chen AC, Sah RL, Bugbee 3. Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prosthesis.
WD. Prolonged storage effects on the articular cartilage of fresh human osteo- Three to eight-year follow-up of fifty-one consecutive ankles. J Bone Joint Surg
chondral allografts. J Bone Joint Surg Am. 2003 Nov;85-A:2111-20. 85:1321-1329, 2003.

2. Brage ME, Bugbee W, Tontz W. Intraoperative and postoperative complications of 4. Wood P, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone
fresh tibiotalar allografting. Presented at the AOFAS Winter Meeting 2002. Joint Surg Br 85:334-341, 2003.

3. Kim CW, Jamali A, Tontz W, Convery R, Brage M, Bugbee W. Treatment of post- Ankle arthrodesis
traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts. 1. Muir D, Amendola A, Saltzman C. Long-term outcome of ankle arthrodesis. Foot
Foot Ankle Int 23:1091-1102, 2002. Ankle Clin 7:703-708, 2002.
4. Tontz W, Bugbee W, Brage M. Use of allografts in the management of ankle 2. Coester L, Saltzman C, Leupold J, Pontarelli W. Long-term results following ankle
arthritis. Foot Ankle Clinics 8:361-373, 2003. arthrodesis for post-traumatic arthritis. J Bone Joint Surg 83:219-228, 2001.
5. Meehan R, McFarlin S, Bugbee W, Brage M. Fresh ankle osteochondral allograft 3. Thomas R, Daniels T, Parker K. Gait analysis and functional outcomes following
transplantation for tibiotalar joint arthritis. Foot Ankle Int 26:795-802, 2005. ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg 88:526-535, 2006.
6. Vora A, Parks B. Early failure of bipolar osteochondral tibiotalar allograft replace-
ments. Presented at the AOFAS Winter Meeting 2005. (Levels of evidence: For all of the ankle transplant and total ankle replacement arti-
cles, Level IV case series.)
Total ankle replacement
1. Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG,
Saltzman CL. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up.
J Bone Joint Surg Am. 86:1161-71, 2004.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
120 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 121

BENCHTOP TO BEDSIDE: EXAMINING THE

BARRIERS BETWEEN THE RESEARCH

SYMPOSIA GENERAL
LABORATORY AND THE CLINICAL SETTING (E)
Moderator: Cato T. Laurencin, MD, Earlysville, VA (e - Osteotech, Synthes, Smith & Nephew)
The advent of an aging US population has demanded new and innovative treatments for
orthopaedic injuries. Research into new and innovative treatment modalities is active and
ongoing but a communication gap exists between the research and clinical realm. In many
instances this gap creates a barriers to the most successful research innovations from being
actualized in the clinical setting. The goal of this symposium is to begin to bridge this gap
by taking the research to the clinician and examining what is necessary to more efficiently
move highly successful research into the clinical realm. Using osteoarthritis as a model, this
symposium will examine current clinical approaches to treating osteoarthritis, cutting-edge
ongoing research into the disorder, and the issues and concerns that exist in bringing
benchtop research to the patient’s bedside.

I. Introduction and Overview

Cato T. Laurencin, MD, Earlysville, VA (e - Osteotech, Synthes, Smith & Nephew)

II. Current Clinical Treatment Strategies For Treating Osteoarthritis

Khaled J. Saleh, MD, charlottesville, VA (a, e – Stryker, a, c, e – Smith & Nephew)

III. Panel Discussion: How Successful are the Latest Strategies? Are They Effective?
Panel

IV. Current Progress on the Etiology of Osteoarthritis

Gary Balian, MD Charlottesville, VA (a, c - Exactech, a, b - DePuy, a - Zimmer

V. Tissue Engineering Of Osteochondral Tissue

Robert L-Y Sah, MD, La Jolla, CA (a - Articular Engineering, Synthasome, Wyeth,
b – Arthrex, BREG)

VI. Lessons Learned from the Basic Science About Osteoarthritis. How Is This
Information Translated Into Meaningful Information For the Clinician
Panel

VII. FDA Issues Involved In Bringing Research Projects To The Clinical Realm
Cato Laurencin, MD, Earlysville, VA (e - Osteotech, Synthes, Smith & Nephew)

VIII. Bioethics Of Research And Clinical Application: How Good Does The Data Have To Be
Before We Start Thinking About Patients
William M. Mihalko, MD, Charlottesville, VA (e - Stryker Orthopaedics, Inc)

IX. Supporting Studies Designed to Bring Promising Research to the Bedside

Joshua Jacobs, MD Chicago, IL (a, e - Zimmer, Medtronic, Wright Medical, Archus,
Spinal Motion, e - Isotis)

X. What Are the Real Barriers to Clinical Implementation of Newly Discovered Therapies
and Treatments
Panel

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
121
SYM 07:Layout 1 1/12/07 11:40 AM Page 122

INTRODUCTION AND OVERVIEW

Cato T. Laurencin, MD

a. Definition of Translational Research: b. Importance in clinical realm

From the Coulter Foundation website (www.whcf.org): • Allows for the newest treatments with the highest poten-
1. It is driven primarily by considerations of use and practi- tial to be actualized
SYMPOSIA GENERAL

cal application of the research results, as opposed to

c. Relevance and priority in the research realm
basic research, which is driven primarily by a quest for
• Allows for the newest treatments with the highest poten-
knowledge.
tial to be actualized
2. It envisions the development of a practical solution that
• Motivation for researchers and physicians is the same, to
addresses a particular clinical problem or unmet clinical
improve the health and quality of life of the population.
need.
Two common goals formerly separated by a wide abyss
3. The research results generally include protectable intel-
of regulatory issues, funding constraints, and market
lectual property.
driven product development
4. It involves clinical application as a goal, and therefore
requires a transition or translation of the research from a d. Goals and structure of the symposium
research laboratory to the clinic – from bench to bedside. • Current Clinical Treatment Strategies (Khaled Saleh)
5. It often envisions a particular product as the endpoint of • Current Progress in Osteoarthritis (Gary Balian)
development. • Tissue Engineering of Osteochondral Tissue (Xudong Li,
6. It involves commercialization as a goal and therefore Robert Sah)
requires a transfer of the technology from the academic • FDA Considerations in Translational Research (Cato
institution to a commercial entity for final product devel- Laurencin)
opment, manufacturing, marketing and sales. • Bioethics of Research and Clinical Application (William
Journal of Translational Medicine Mihalko)
• Supporting Translational Research (Joshua Jacobs)
• Periodic Panel Discussions to expand topic

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
122 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 123

CURRENT CLINICAL TREATMENT STRATEGIES FOR TREATING

OSTEOARTHRITIS
Khaled J. Saleh, MD

a. Current approaches for treating osteoarthritis c. Next generation (currently available clinical strategies)

SYMPOSIA GENERAL
• THA, Core decompression, hyaluronic acid injection, treatment options
glucosamine and chondroitin sulfate • OATS, Carticel, etc.
b. Effectiveness of current osteoarthritis treatments d. What do surgeons want/need to be more effective healers
• Percent revisons, age of revisions, how long initial THA • Products that are as good/better than existing materials,
lasts, effectiveness of preventative treatments (Glucos. ease of use, cost-effective, minimal to no follow-up
Chond sulf)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
123
SYM 07:Layout 1 1/12/07 11:40 AM Page 124

PANEL DISCUSSION: HOW SUCCESSFUL ARE THE LATEST

STRATEGIES? ARE THEY EFFECTIVE?
(Panel)

a. Critical assessment of current treatment strategies for c. Suggestion of where current research should be heading to
SYMPOSIA GENERAL

osteoarthritis meet the needs of surgeons today

b. Carticel, OATS, relationship to tissue engineering, biologics-
based healing strategies

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
124 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 125

CURRENT PROGRESS ON THE ETIOLOGY OF OSTEOARTHRITIS

Gary Balian, MD

Osteoarthritis entails changes in the composition of articular The etiology of osteoarthritis will be discussed based on
cartilage, including water, collagen and proteoglycans. A combi- a) the differentiation state of chondrocytes and the role of
nation of cellular and consequently biochemical effects lead to transcription factors that regulate gene expression

SYMPOSIA GENERAL
alterations in mechanical properties. Although the disease is b) synthesis of collagens and proteoglycans that are responsi-
more common in older adults, the pathophysiology of joint ble for the integrity and function of the cartilaginous matrix
degeneration, with the associated osteophytes in the margins and its mechanical properties
and subchondral sclerosis, is usually seen in weight-bearing c) the potential role of proteases that regulate matrix accumu-
joints and is associated with stresses that are due to obesity and lation and degradation
overuse. In addition, minesectomy is known to lead to d) a molecular basis for the integrity of cartilage extracellular
osteoarthritis. matrix, the retention of water and the mechanical properties
of articular cartilage
Chondrocytes respond to changes in their environment and
e) molecular genetics and the role of gene and protein arrays
thereby affect the extracellular matrix of cartilage. The regulation
in determining the etiology of degenerative arthritis
of chondrocyte metabolism, possibly at the transcriptional and
translational levels, alters the differentiation state of chondro-
cytes, and in succession the nature of articular cartilage and the
mechanical properties of joint surfaces.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
125
SYM 07:Layout 1 1/12/07 11:40 AM Page 126

BIOENGINEERING OF OSTEOCHONDRAL TISSUE

Robert L-Y Sah, MD

Osteoarthritis and current treatment • Cartilage bulk

• Limits to regeneration • Cartilage-cartilage interface
— Avascular, aneural • Cartilage-bone interface
SYMPOSIA GENERAL

— Relatively low cell density

Stem cells therapy
— Cells of low mitotic activity
• Chondrocyte
Therapeutic Strategies for Articular Cartilage Degeneration — Three-dimensional imaging
• Target specific disease, at defined stage — Advantage
• Counter pathogenesis — Disadvantage
• Stem cells
Cartilage repair
— Different sources
• Microfracture repair
— Advantage
— Cells from marrow – Form fibrocartilage, poor dura-
— Disadvantage
bility
Biomaterials
Cartilage repair
• Natural
• Autologous chondrocyte implantation
• Synthetic
• Osteochondral Graft
• Ideal biomaterial
• Total joint replacement
• Active biomaterials
• Biological joint replacement
— Gene seeded biomaterials
Tissue Engineering
Growth factor
• Application of principles and methods of engineering
• Protein
and life sciences to
• Gene delivery
— Understand composition-structure-function[-metabo-
— Plasmid, virus, electrophoration
lism] relationships in normal and pathological tissues
— Develop biological substitutes that restore, maintain, Bioreactor – Mechanical factors
or improve tissue functions • Rotating bioreactor
• Mechanical environment
Large full thickness defect – Bioengineered Osteochondral
— Dynamic shear stimulation
Graft
Evaluation of Engineering cartilage
Cartilage repair: time scales
• Matrix component
• Cell adhesion, migration
• Subchondral bone
• Cell differentiation, proliferation, apoptosis
• Biomechanics
• Matrix remodeling
— Indentation test
Tissue Engineering Paradigm
Cell-matrix interaction
• Tissue
• Cell density
— Cartilage
• Matrix accumulation
— Bone, bone marrow
• Implant Integration with native tissue
— Perichondrium, periosteum
• Cartilage
• Cells
• Subchondral bone
— Chondrocytes
— Osteoblasts Breakthrough
— Stem cells • Focal area
• Biomaterials • Total joint
— Collage, hyaluronan
Future Implantation
— PLAGA
• When
— Tricalcium phosphate, hydroxyapatite
— Freshly seeded scaffold
• Growth Factors
— Cultured in vitro for?
— BMP, FGF, PDGF, PG4
• How
• Mechanical Factors
— Anchor engineered implant
— Compression Tension, Shear, Combined loading
— Cell viability during insertion
Cartilage repair – Spatial Specificity • Protection from inflammatory environment
• Articular surface

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
126 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 127

PANEL DISCUSSION: LESSONS LEARNED FROM THE BASIC SCIENCE

ABOUT OSTEOARTHRITIS. HOW IS THIS INFORMATION TRANSLATED
INTO MEANINGFUL INFORMATION FOR THE CLINICIAN
Panel

SYMPOSIA GENERAL
a. Progress made in basic science knowledge c. Relationship between basic science/applied research strate-
b. Translation of basic science knowledge to applied research gies to clinical realm
strategies d. Progressing from the research lab to the FDA approval
process

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
127
SYM 07:Layout 1 1/12/07 11:40 AM Page 128

FDA ISSUES INVOLVED IN BRINGING RESEARCH PROJECTS TO

THE CLINICAL REALM
Cato Laurencin, MD

a. Challenges to FDA approval d. FDA considerations to be discussed at the outset of applied

SYMPOSIA GENERAL

b. Reasons high-potential projects get stuck at the FDA research projects

c. Role of industry in the road through the FDA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
128 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 129

BIOETHICS OF RESEARCH AND CLINICAL APPLICATION: HOW

GOOD DOES THE DATA HAVE TO BE BEFORE WE START
THINKING ABOUT PATIENTS
William M. Mihalko, MD

SYMPOSIA GENERAL
The multiple layers of issues concerning new medical technol- III. The Manufacturer
ogy will be discussed in the presentation. Topics of interest a. Reports of implant failures
from the researcher and reporting data to the FDA approval b. Change in manufacturing processes
process and finally the roles of the manufacturer and physician c. Direct patient marketing
will be presented for panel and audience debate.
IV.The Physician
I. The Researcher a. Issues in off label use of implants
a. Proper reporting of methods and results b. What are the physician’s role in patient disclosure
b. Is the application of the technology sound
II. The FDA
a. Committee members roles in approval process
b. Are dissenting opinions really heard

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
129
SYM 07:Layout 1 1/12/07 11:40 AM Page 130

SUPPORTING STUDIES DESIGNED TO BRING PROMISING

RESEARCH TO THE BEDSIDE
Joshua Jacobs, MD

Introduction Clinical and Translational Science Awards (CTSA)

SYMPOSIA GENERAL

The conventional wisdom of federal policy makers is that the basic One outcome of the NIH Roadmap initiative is the development
science advances achieved by the biomedical research enterprise of a new research infrastructure grant award mechanism (first
have not resulted in commensurate advances in the clinical med- announced in October of 2005) the Institutional Clinical and
icine. Thus, there has been a focused effort to translate basic sci- Translational Science Award (U54). The first round of 12 awardees
ence advances into real improvements in the quality of healthcare. was announced in October of 2006 and up to 60 such institu-
tional awards are anticipated by 2012. The purpose of this new
NIH Roadmap Initiative
grant mechanism “…is to assist institutions to create a uniquely
The current director of the National Institutes of Health, Elias A.
transformative, novel, and integrative academic home for Clinical
Zerhouni, M.D., recognized this state of affairs and posed the
and Translational Science that has the resources to train and
question “What novel approaches can be developed that have
advance a cadre of well-trained multi- and inter-disciplinary inves-
the potential to be truly transforming for human health?”1 In an
tigators and research teams with access to innovative research tools
attempt to answer this question, the scientific leadership of the
and information technologies to promote the application of new
NIH in consultation with prominent extramural scientists,
knowledge and techniques to patient care”.4 This mechanism will
developed the NIH Roadmap for Medical Research that has the
eventually supplant General Clinical Research Center grants and
following three themes.2
will be broader is scope, involving a large training component.
New Pathways to Discovery
Centers of Research Translation Awards (CORT)
This theme aims to provide a solid scientific foundation of new
The National Institute of Arthritis, Musculoskeletal and Skin
strategies for diagnosing, treating, and preventing disease. These
Diseases (NIAMS), the home for the majority of federally fund-
strategies involve exploiting known biological pathways, net-
ed musculoskeletal research, recently developed the CORT
works and molecular libraries. In addition, new tools and meth-
mechanism to address the perceived gap in research translation.
ods in the disciplines of molecular imaging, structural biology,
This mechanism has replaced other large grant mechanisms
bioinformatics, computational biology, and nanomedicine will
(such at the Specialized Center of Research or SCOR Grants)
be employed to achieve this aim.2
“…to foster research that is translational in nature, directed at
Research Teams of the Future elucidating the relevance of basic research to human disease…“
This theme recognizes the imperative of cross-disciplinary col- Translational research is defined as applied and clinical scientif-
laborations in the conduct of modern biomedical research. ic research that is directed towards testing the validity and limits
These collaborations need to occur between physical and bio- of applicability of knowledge derived from basic science and
logical scientists; between the public and private sectors; engineering to the understanding of human diseases and
between bench scientists and clinical researchers. health.”5 The expectation is that interdisciplinary teams of
researchers will approach specific musculoskeletal diseases and
Re-engineering the Clinical Research Enterprise
elucidate the clinical relevance of basic science advances. Like the
The aim of modern biomedical research is to translate basic sci-
CTSA, the CORT has translational research as its central focus.
ence discoveries into novel drugs, diagnostics or methods of
prevention. This requires a robust clinical research enterprise Commentary
that currently is under siege from a variety of societal, econom- For orthopaedic surgeons on the “front lines” of musculoskele-
ic and regulatory forces. The NIH’s goal is to promote the inte- tal disease management, the focus on translational research is
gration of existing clinical research networks, encourage the welcome news. Orthopaedic research has always had a strong
development of technologies to improve the assessment of clin- multidisciplinary component, involving clinicians, engineers,
ical outcomes, harmonize regulatory processes and enhance and life scientists. Our specialty and subspecialty organizations
training for clinical researchers.2 need to leverage this ongoing investment in translational
research and individual orthopaedic practices, whether they are
Dr. Zerhouni opines that these roadmap themes, taken togeth-
in large public academic institutions in small private settings,
er, recognize that “many fundamental aspects of biology in
need to support the clinical research enterprise. The orthopaedic
health and disease is still insufficient to translate current find-
surgical research community needs to be cognizant of these
ings reliably into new and more effective prevention and treat-
developments in the funding of translational research as we (and
ment” and that “focused and significant commitment to the cre-
our patients) stand to greatly benefit from the introduction of
ation of a new, vital and reinforced academic discipline and
novel, effective methods to diagnose, treat and/or prevent mus-
home for translational and clinical science…will ensure that
culoskeletal disorders. If we do not participate in these and other
extraordinary scientific advances of the past decade will be rap-
translational research mechanisms, we run the risk of being left
idly captured, translated, and disseminated for the benefit of all
behind and our specialty (and our patients) will suffer.
Americans.”1 While the roadmap initiative currently involves
only 1.2% of the NIH budget in fiscal year 20063, increasing
investment is anticipated in the future.
REFERENCES 3. Fact Sheet NIH Roadmap for Medical Research
1. Zernouni, E.A. Translational and Clinical Science – Time for a New Vision. N http://opasi.nih.gov/documents/NIHRoadmap_FactSheet_Aug06.pdf
Engl J Med 353:1621-1623, 2005. 4. Institutional Clinical and Translational Science Award (U54).
2. NIH Roadmap for Clinical Research. http://nihroadmap.nih.gov/overview.asp http://grants1.nih.gov/grants/guide/rfa-files/RFA-RM-07-002.html
5. NIAMS Mechanism P50: Centers of Research Translation.
http://www.niams.nih.gov/rtac/funding/grants/cortwww.htm

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
130 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 131

PANEL DISCUSSION: WHAT ARE THE REAL BARRIERS TO

CLINICAL IMPLEMENTATION OF NEWLY DISCOVERED THERAPIES
AND TREATMENTS
Panel

SYMPOSIA GENERAL
a. Barriers between successful research projects and clinical application c. Path from academic research to clinical application
b. Regulatory, ethical, intellectual property

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
131
SYM 07:Layout 1 1/12/07 11:40 AM Page 132

TECHNIQUES FOR TIBIAL DEFORMITY

CORRECTION: STATE OF THE ART (R)
SYMPOSIA GENERAL

Co-Moderators: S. Robert Rozbruch, MD, New York, NY (a - Smith and Nephew, EBI)
and Mark T. Dahl, MD Stillwater, MN (n)

State of the art techniques for tibial deformity correction include intramedullary nailing,
plating, monolateral and circular external fixation. After a session on principles and
planning, these approaches will be reviewed to highlight optimal indications for each
method.

I. Principles and Planning

Dror Paley, MD, Baltimore, MD (e - Smith & Nephew)

II. Intramedullary Nailing

David L. Helfet, MD, New York, NY (e – Synthes)

III. Plating (Fixator assisted)

Joachim Pfeil, MD, Wiesbaden, Germany (n)

IV. Monolateral External Fixation (Multi-axial correction)

Richard S. Davidson, MD, Philadelphia, PA (EBI)

V. Circular External Fixation (Six axis correction)

S. Robert Rozbruch, MD New York, NY (a - Smith and Nephew, EBI)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
132 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 133

PRINCIPLES AND PLANNING

Dror Paley, MD

Frontal Plane Mechanical Axis the orientation angle relative to the frontal or sagittal planes
the line from the center of the femoral head (hip) to the center
Apical Direction
of the tibial plafond (ankle)
the direction in which the apex points in the true plane of

SYMPOSIA GENERAL
Mechanical Axis Deviation (MAD) angulation, defined relative to the reference plane directions
the distance from the center of the knee to the crossing point • anterior (A), posterior (P), medial (M), and lateral (L) or
of the mechanical axis line combinations (AM, AL, PM, and PL)
For each plane of angulation, there are two apical directions.
Malalignment
• e.g., frontal plane: M (valgus) and L (varus)
the presence of MAD greater than normal (normal, 8+/7)
Magnitude
Mechanical Axis of a Bone
the longitudinal angle (rather than the transverse angle)
the line connecting the center of the proximal joint and the
between the intersecting axis lines in the true plane of angula-
center of the distal joint (always straight)
tion
Anatomic Axis of a Bone
Method to Determine the Level of Angulation
the mid-diaphyseal line of a bone (curved or straight)
Step 1. Draw the proximal axis line.
Joint Line Orientation Angle (JLOA) Step 2. Draw the distal axis line.
an angle between the axis line, mechanical (m) or anatomic Step 3. Mark the CORA at the intersection of the axis lines.
(a), and the joint line, usually named on the side that normal-
Mechanical Axis Planning Method
ly is less than 90°
Generate proximal and distal mechanical axis lines and find
JLOA Nomenclature their intersection.
• medial (M) or lateral (L) and anterior (A) or posterior (P)
Anatomic Axis Planning Method
to the axis line
Generate proximal and distal anatomic axis lines and find
• proximal or distal end of the bone
their intersection.
• name of the bone
Note: The mechanical and anatomic axis lines in the tibia are
e.g., Mechanical Lateral Distal Femoral Angle (mLDFA)
so similar that the results are almost the same. Therefore,
• the angle between the mechanical axis line and the knee
there is essentially only one planning method for the
joint
tibia. (We use mechanical axis planning for most tibial
• line measured on the lateral side of the axis line
deformities, with the exception of mid-diaphyseal post-
Anatomic Lateral Distal Femoral Angle (aLDFA)
fracture tibial deformities, for which mid-diaphyseal
• the angle between the anatomic axis and the knee joint line
lines [the anatomic axis method] may be easier to use.
• measured on the lateral side of the axis line
In the femur, the mechanical and anatomic axis lines are
Malalignment Test (MAT) so different that we have two separate planning meth-
• test to determine the source of MAD, essentially a malorien- ods: mechanical and anatomic.)
tation test of the knee joint
Method to Generate the Proximal Tibial Mechanical Axis
Step 1. Measure mMPTA: if <85° or >90° component of
Line (PTMAL)
MAD secondary to tibial deformity (varus and valgus,
Step 1. Start at the center of the tibial knee joint line.
respectively)
Step 2. Draw the axis line at the JLOA based on the following.
Step 2. Measure the mLDFA: if <85° or >90° component of
• If the ipsilateral mLDFA is normal, extend the
MAD secondary to femoral deformity (valgus or varus,
femoral mechanical axis line distally to become the
respectively)
PTMAL.
Proximal and Distal Axis Lines • If the ipsilateral mLDFA is abnormal but the con-
When a bone is deformed in angulation, the original mechani- tralateral mMPTA is normal, use it as a template
cal and anatomic axis lines break and are angulated with the angle to generate the PTMAL.
bone. The axis line proximal to the break is the proximal axis • If both of the above angles are abnormal, use the
line, and the axis line distal to the break is the distal axis line. average normal mMPTA = 87°.
Center of Rotation of Angulation (CORA) Method to Generate the Distal Tibial Mechanical Axis Line
the point of intersection of the proximal and distal axis lines (DTMAL)
Step 1. Start at the center of the ankle joint line.
Angulation
Step 2. Draw the axis line based on the following.
defined by four parameters
• If the distal tibial diaphysis is straight, draw the axis
1) Level
line parallel to the distal anatomic axis (mid-dia-
2) Plane
physeal line).
3) Apical direction
• If there is too short a distal segment and an accu-
4) Magnitude
rate mid-diaphyseal line cannot be drawn, use the
Level mLDTA to draw the distal axis line using the con-
the distance from the proximal or distal joint line to the CORA tralateral mLDTA as a template angle if it is normal
and mLDTA = 90° if the contralateral mLDTA is
Plane
abnormal.
the plane of the two intersecting axis lines in space, defined as
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
133
SYM 07:Layout 1 1/12/07 11:40 AM Page 134

Malorientation Test (MOT) The Bisector Line

Tests the joint orientation of the hip and ankle to the mechan- the line bisecting an angle into two halves of equal magnitude
ical or anatomic axis lines. (The bisector line of an angular deformity is drawn through
Step 1. Draw the distal anatomic or mechanical axis line of the CORA bisecting the transverse angle.)
the tibia or femur.
Other CORAs
Step 2. Draw the joint line of the ankle or hip, respectively.
each point on the bisector line is considered a CORA
Step 3. Measure the respective JLOA. If the particular JLOA is
abnormal, then there is malorientation of that joint. Axis of Correction of Angulation (ACA)
SYMPOSIA GENERAL

the imaginary line around which the angular correction is per-

Multiapical Deformities
formed
deformities with more than one CORA in one bone
Opening Wedge Osteotomy
Diagnosing Multiapical Deformities with Axis Planning
an angular correction osteotomy, the ACA of which passes
• The proximal and distal axis lines always intersect at one
through a CORA at the point at which the bisector line inter-
CORA. Some characteristics of that CORA indicate that
sects the convex cortex of the bone
there are multiple CORAs.
• If the CORA is at a level of no obvious deformity or is well Closing Wedge Osteotomy
outside the bone in the tibia, for anatomic axis planning for an angular correction, the ACA of which passes through a
the femur, the deformity is multiapical. In such cases, draw CORA at the point at which the bisector line intersects the
a third (middle) axis line that corresponds to the mid-dia- concave cortex of the bone
physis in the tibia for mechanical or anatomic axis planning
Dome Osteotomy
and the femur for anatomic axis planning or that is 7° from
a circular bone cut that in three dimensions is a cylinder
the anatomic axis for mechanical axis planning for the
femur. Focal Dome Osteotomy
• If the CORA is at the level of the obvious deformity but the a dome osteotomy with which the center of the circular cut is
MOT demonstrates an abnormal ankle or hip joint orienta- a CORA on the bisector line and with which the ACA passes
tion in tibial or femoral planning, respectively, then there is through the CORA
a second CORA at the level of the ankle or hip, respectively.
Osteotomy Rule 1
Sagittal Plane MAT and MOT When the osteotomy and the ACA both pass through a CORA,
In the sagittal plane, there are also normal joint line orienta- the osteotomy correction will fully realign the axes of the bone
tion angles. If these are abnormal, then there is a deformity of by angulation of the bone ends to the magnitude of the defor-
the femur or tibia. mity.
Sagittal Plane Anatomic Axis Planning Osteotomy Rule 2
• Both anatomic and mechanical axes can be generated in the When the osteotomy is at a different level from that of a
sagittal plane. Mechanical axes do not have much signifi- CORA but the ACA passes through a CORA, then the osteoto-
cance in the sagittal plane; therefore, we use anatomic axis my correction will fully realign the axes of the bone by angula-
planning for the sagittal plane. tion and translation of the bone ends.
• To generate the proximal and distal anatomic axis lines, fol-
Osteotomy Rule 3
low the same principles and steps as for anatomic axis plan-
If the osteotomy is at a different level than the CORA and the
ning of the frontal plane.
axis of correction of angulation is not at the CORA, the proxi-
Step 1. If there is a diaphyseal deformity, then use two mid-
mal and distal axes of the bone will translate to each other. If
diaphyseal lines. If there is no diaphyseal deformity,
the axis is at the osteotomy level, for example, the osteotomy
then draw one mid-diaphyseal line.
line will not translate despite the translation of the axes.
Step 2: Generate the proximal or distal anatomic axis line
from the joint line at the end of the bone where the Multiapical Deformity Osteotomy Rules:
malorientation test is abnormal. To do this, we need a In a case of multiapical deformities, an osteotomy at the reso-
starting point (SP) on the joint line and a JLOA. It is lution point CORA will realign the mechanical but not the
best to use the SP as on the opposite side if the oppo- anatomic axis. Multilevel osteotomies are needed to realign
site side is normal (MAT and MOT). If the opposite both anatomic and mechanical axesThe middle axis line can
side is abnormal, then use an average normal SP at be altered from the optimal location to various orientations to
the average normal IPD. alter the level and magnitudes of the CORAs. Correction at
Step 3: Mark the CORAs at the intersection point of each pair these levels will produce complete mechanical axis realign-
of axis lines. ment with residual anatomic axis deformity.
Reference Plane Angulation Translation Deformity
angulation in the frontal or sagittal planes Defined by four parameters:
• Level
Oblique Plane Angulation
• Plane
angulation in a plane other than the frontal or sagittal planes
• Direction
Determining the Magnitude of and Plane Orientation in • Magnitude
Oblique Plane Deformities
Level of Translation
The plane of angulation can be determined accurately by using
the region of overlap of bone segments
trigonometric formulae. Alternatively, it can be determined
using an approximation (the graphic method). See Chapter 61 Direction of Translation
in Chapman’s Orthopedics, 1993, for a description of these distal relative to proximal
methods.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
134 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 135

Magnitude of Translation Knee: The knee has no compensatory mechanism in the

the perpendicular distance from the proximal to the distal axis frontal plane. In the sagittal plane, the knee joint com-
lines at the level of the distal end of the proximal segment pensates for malorientation of the distal femur or proxi-
mal tibia caused by sagittal plane deformities. If the
Plane of Translation
joint compensation becomes a fixed contracture in the
orientation of the plane of axis lines, measured using the
compensatory direction, then osteotomy correction to
graphic method
reorient the maloriented end of the bone will uncover
Complex Deformities Angulation and Translation the fixed contracture (e.g., valgus deformity of ankle pla-

SYMPOSIA GENERAL
usually fracture deformities with angulation and translation fond). If the subtalar joint develops a fixed inversion
Same plane: contracture to compensate, then after supramalleolar
• corrected around one ACA at point of resolution of correction of the ankle plafond orientation, the heel will
angulation and translation, or be in fixed varus.
• corrected at fracture level with angulation and translation
Ligamentous Sources of Malalignment
corrected separately
Medial Collateral Ligament (MCL) Laxity
Different planes:
• can produce valgus MAD 2° chronic stretch from valgus
• There is no way to resolve into one ACA. Therefore, can
• deformity (e.g., pseudoachondroplasia)
be corrected by one ACA for angulation and separate
Lateral Collateral Ligament (LCL) Laxity
translation correction.
• can produce varus MAD 2° chronic stretch from varus
The graphic method is used to plot the plane of angulation
• deformity (e.g., Blount’s, rickets, medial OA), 2° overgrowth
and translation on the same graph.
of proximal fibula (e.g., achondroplasia, growth arrest
Complex Deformities Angulation and Rotation tibia), 2°
• Angulation and rotation can be corrected sequentially by • iatrogenic (e.g., valgus HTO with resection of proximal
correcting angulation first and then rotation around the axis tibia-fibula joint resulting in proximal fibular head migra-
of the realigned bone. tion)
• Angulation and rotation can be resolved into one plane
Treatment of Malalignment Caused by LCL or MCL
and, therefore, one ACA. Special osteotomies, e.g., inclined
• Realign and allow ligament to retighten on own under pro-
osteotomy (Rab), can be used to correct both angulation
tection of 2° muscular stabilizers.
and translation around a vertically inclined ACA.
• Overcorrection of bone problem is 2° bony deformity.
Joint Considerations for Angular Deformity Corrections • Retension ligament (direct or indirect/acute or gradual)
Ankle: The subtalar joint compensates for frontal plane malo-
rientation of the ankle joint. Similarly, in the sagittal
plane, the ankle joint compensates for malorientation
of the distal tibia.

REFERENCES 7. Paley D, Herzenberg J, Tetsworth, K, et al: Deformity planning for frontal and
1. Green SA, Gibbs P: The relationship between angulation to translation in fracture sagittal plane corrective osteotomies. Orthop Clin North Am 25:425465, 1994.
deformities. J Bone Joint Surg Am 76:390397,1994. 8. Paley D, Maar D, Herzenberg J: New concepts in high tibial osteotomy for medi-
2. Green SA, Green HD: The influence of radiographic projection on the appear- al compartment osteoarthritis. Orthop Clin North Am 25:48398, 1994.
ance of deformities. Orthop Clin North Am 25:467475, 1994. 9. Paley D, Bhatnagar J, Herzenberg J, Bhave A: New procedures for tightening knee
3. Paley, D: Principles of Deformity Correction. Berlin, Springer-Verlag, 2002. collateral ligaments in conjunction with knee realignment osteotomy. Orthop
Clin North Am 25:53355, 1994.
4. Paley D, Tetsworth K: Preoperative planning of uniapical angular deformities.
Clin Orthop 280:4864, 1992. 10. Tetsworth K, Paley D: Accuracy of correction of complex lower extremity defor-
mities by the Ilizarov method. Clin Orthop 301:102110, 1994.
5. Paley D, Tetsworth K: Preoperative planning of multiapical angular deformities.
Clin Orthop 280:6571, 1992. 11. Tetsworth K, Paley D: Malalignment and degenerative arthropathy. Orthop Clin
North Am 25:367378, 1994.
6. Paley D, Tetsworth K: Principles of deformity correction by the Ilizarov method.
In, Chapman (ed): Operative Orthopedics. Philadelphia, Lippincott, ed 2, vol 1,
pp 863948, 1993.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
135
SYM 07:Layout 1 1/12/07 11:40 AM Page 136

TECHNIQUES FOR TIBIAL DEFORMITY CORRECTION:

INTRAMEDULLARY NAILING
David L. Helfet, MD

I. TIBIAL NONUNIONS 5. “Management of malunion and nonunion of the

SYMPOSIA GENERAL

A. Background tibia” [Johnson, 1987]

1. Most Common 2-10% [Patel, 2004] a. Significant Deformity Requiring open Correction
a. Greater Incidence Associated with (Especially Proximal/Distal 1/3)
— Energy Injuries • Prior Sepsis
— Open Fractures — Pin Tracts
2. Most Refractory — Fracture
B. Treatment of Choice 6. “Nonunions of the distal tibia treated by reamed IM
1. Reamed Nailing nailing” [Richmond/Helfet, 1987]
a. Stable Fixation • Distal ¼ Tibia NonunionsN=32
b. Load Bearing — Difficulty in Treatment
c. Autologous Bone Graft — Short Segment
d. Locking — Increased Proximity to Ankle Joint
— 10 cm < Knee — Fragile Soft Tissue Envelope
— 10 cm > Ankle • Retrospective Review
• Correct Deformity a. Initial Treatment
• Reaming/Other Bone Graft • Ex-Fix (Removal Prior to nail) (8/32) 25%
• Locked Nailing • Cast Immobilization (5/32) 16%
2. “Nonunion of the Tibia Treated with a Reamed IM • Intramedullary Nail (8/32) 25%
Nail” [Wiss/Stetson, 1994] • Enders Nail (1/32) 3%
a. Tibial Nonunions (47) • Isolated Lag Screws (3/32) 9%
• Closed (14/47) 30% • Plate and Screws (7/32) 22%
• Open (33/47) 70% b. Infection History (7/32) 22%
b. Results Active Infection at Time of Revision(0/32) 0%
• Reamed IM Nailing (47/47) 100% c. Results
— Closed (44/47) 94% • Union Rate (29/32) 91%
— Open (3/47) 6% • Nonunion Rate (3/32) 9%
• Union Rate (42/47) 89% — Dynamized Union (2/32) 6%
• Infection (6/47) 13% — Exchange Nail Union (1/32) 3%
• Previously Open Fractures (5/6) 83% • Average Months of Follow-up 25
• Union after Revision/s (6/6) 100% (Range 4-81 months)
3. “The Treatment of Noninfected Pseudoarthrosis of the • Deformity Corrected to Maximum of 4°
Femur and Tibia with Locked IM Nailing” [Kempf, In All Planes
1986] • Positive Intra-operative Cultures (4/32) 13%
a. Tibia Nonunions (Pseudarthrosis) 39 — Requiring ROH after Union (2/32) 6%
• Union (One Operation) 94.8% — No Sign/Chronic Osteomyletis
• Infection 7.0% (at Last FU 5.5 Years & 2 Years)
• Deformity (>5°) 18.0% d. Conclusions
• F.R.O.M. 85.0% • “For tibial nonunion WITH deformity, NOT
4. When is IM Reamed Nailing Contraindicated for amenable to locked IM Nailing”
Diaphyseal Nonunions of the Lower Extremity — Limited Open Deformity Correction
ALMOST NEVER! — Indirect Reduction (Femoral Distractor)
a. “Treatment of open tibial-shaft fractures: — Tension Band Plating
• External fixation and secondary IM nailing” • “Biological” Modification of Standard Plating
[McGraw/Lim, 1988] (with Soft Tissue/Vascularity Preservation)
— Prior External Fixation • 100% Union Rate
– Up to 44% Infection Rate — with Acceptably Complication Rate
b. Prior Sepsis • Deep Infection Rate of 3%
• Pin Tracts — Open Treatment Tibial Nonunion

• Always Augment with ≥ 1 Lag Screw

• Fracture (Literature Review 5 44%)
c. Significant Deformity Requiring Open Correction
• Especially Proximal/Distal 1/3 • Autogenous Bone Grafting
[Johnson KD, 1987] — Oligatrophic or Atrophic Nonunions
REFERENECES: 2. BOHLER J: Treatment of Nonunion of the Tibia with Closed, Semiclosed
1. Bach AW, Hansen ST JR: Delayed Union, Nonunion, Malunion of the Tibial Intramedullary Nailing. Clin. Ortho., 43:93 101, 1965.
Shaft. In: Surgery of the Musculoskeletal System, pp. 8:63 8:86. Edited by C.McC. 3. Brighton CT, Black J, Friedenberg ZB, Esterhai JL, Day LJ, Connolly JF: A
Evarts. New York, Churchill Livingstone, 1983. Multicenter Study of the Treatment of Nonunion with Constant Direct Current.
J. Bone Joint Surg, 63B:2, 1981.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
136 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 137

4. D'Aubigne RM: Treatment of juxta-articular nonunion associated with joint stiff- 18. Müller ME, Allgower M, Schneider R, Willenegger H: Manual of Internal Fixation,
ness. Traumatismes Anciens, Paris, Masson253-253, 1958 New York, Springer & Veslag, 1979.
5. Goulet J, Bray TJ: Nonunions, Malunions of the Tibia. In: Operative 19. Müller ME, Thomas RJ: Treatment of Nonunion in Fractures of Long Bones. Clin.
Orthopaedics, pp. 581 596. Edited by M.W. Chapman. Philadelphia, Lippencott, Ortho., 138:141 153, 1979.
1988. 20. Müller ME: Biomechanical Principles in the Treatment of Delayed Union,
6. Green SA, Garland DE, Moore TJ, Barad SJ: External Fixation for the Uninfected Pseudarthrosis. J. Bone Joint Surg[AM], 43:291 292, 1961.
Angulated Nonunion of the Tibia. Clin. Ortho., 190:204 211, 1984. 21. Müller ME: Treatment of Nonunions by Compression. Clin. Ortho., 43:83 92,
7. Gustilo RB, Mendoza RM, Williams DN: Problems in the Management of Type 1965.
III (Severe) Open Fractures: A New Classification of Type III Open Fractures. J.

SYMPOSIA GENERAL
22. Patel M, McCarthy J: "Tibial Nonunions", eMedicine Journal, April 2004.
Trauma, 24:742 746, 1984.
23. Richmond J, Colleran K, Borens O, Helfet DL: Nonnunions of the Distal Tibia
8. Hanson LW, Eppright RH: Posterior Bone Grafting of the Tibia for Non Union. A Treated By Reamed Intramedullary Nailing, J. Orthopaedic Trauma, Submitted,
Review of Twenty four Cases. J. Bone Joint Surg, 48 A:27 43, 1966. August 2002
9. Helfet DL, Jupiter JB, Gasser S: Indirect reduction and tension-band plating of 24. Rosen H: Treatment of Nonunions General Principles. In: Operative
tibial non-union with deformity. J.Bone Joint Surg 74A(9):1286-1298, 1992. Orthopaedics, pp. 489 507. Edited by M.W. Chapman. Philadelphia, Lippincott,
10. Helfet DL, Kloen P, Anand N, Rosen HS: Open reduction and internal fixation of 1988.
delayed unions and nonunions of fractures of the distal humerus. Journal of 25. Rosen H: Compression Treatment of Long Bone Pseudarthrosis. Clin. Ortho.,
Bone and Joint Surgery (Am). Accepted. 138:154 166, 1979.
11. Johnson EE, Marder RA: Open Intramedullary Nailing, Bone grafting for 26. Rosen H: The Treatment of Non union, Delayed Unions of Long Bone Fractures
Nonunion of Tibial Diaphyseal Fracture. J. Bone Joint Surg, 69 A:375 380, 1986. using the AO Compression Technique. J. Bone Joint Surg[AM], 50:831, 1968.
12. Johnson KD: Management of malunion and nonunion of the tibia. 27. Schatzker J: Results of Compression Plating of Closed Nonunions of the Tibia in
Orthop.Clin.North Am 18(1):157-171, 1987. the American Academy of Orthopaedic Surgeons: Symposium in Trauma to the
13. Jones KG: Treatment of Infected Nonunion of the Tibia through the Leg, its Sequelae. In: , pp. 246 257. Edited by C.V. Mosby. St.Louis, 1981.
Posterolateral Approach. Clin. Ortho., 43:103 109, 1965. 28. Sledge SL, Johnson KD, Henley MB, Watson JT: Intramedullary Nailing with
14. Mast JW: Planing, Reduction Technique in Fracture Surgery, Springer Verlag, Reaming to Treat Non Union of the Tibia. J. Bone Joint Surg, 71 A:1004 1019,
1988. 1989.
15. Mast JW: Preoperative Planning in the Surgical Correction of Tibial Nonunions, 29. Tornqvist H: Tibia Nonunions Treated by Interlocked Nailing: Increased Risk of
Malunions. Clin. Ortho., 178:26 30, 1983. Infection after Previous External Fixation. J. Orthop. Trauma, 4:109 114, 1991.
16. Mayo KA, Bernirschke SK: Treatment of Tibial Malunions, Nonunions with 30. Weber BG, Cech O: Pseudarthrosis, New York, Grune & Stratton, 1976.
Reamed Intramedullary Nails. Orthop. Clin. North. Am., 21 No. 4:715 724, 31. Wiss DA, Stetson WB: Nonunion of the tibia treated with a reamed
1990. intramedullary nail. J.Orthop Trauma 1994;8 (3):189-194, 1994.
17. McGraw J, Lim E: Treatment of open tibial-shaft fractures. External fixation and 32. Wiss DA, Stetson WB: Tibial Nonunion: Treatment Alternatives. J.Am
secondary intramedullary nailing. 70: 1988 900-11. Acad.Orthop Surg 1996 Oct;4 (5):249-257, 1996.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
137
SYM 07:Layout 1 1/12/07 11:40 AM Page 138

FIXATOR ASSISTED PLATING - FAP

Joachim Pfeil

Fixator assisted plating (FAP) is performed with the only intra- 5. Osteotomy and fixation of the fragments with the deformity
operative use of an external fixator to achieve and/ or to main- corrected
tain the correction of a deformity. The bone fragments are then 6. (Remove bone edge at the deformity side – especially with
SYMPOSIA GENERAL

fixed with a locking plate. big translation)

7. Apply a locking plate for definitive stabilisation
In the past the intraoperative use of fixators was mainly per-
8. Remove the fixator
formed in fixator assisted nailing procedures. With the avail-
9. (Add cancellous bone graft at the osteotomy side)
ability of locking plates, devices that provide great stability and
reduce the damage to the vascularity of the periostium, plating Which type of fixator is best for FAP?
becomes more important in deformity corrections. FAP pro- In our opinion unilateral fixators build with an off set carbon
vides high precision in corrections with plate stabilisation. FAP bar and with a gradual angulation joint are easy to use as they
is indicated for axial and rotational deformity corrections. allow free access for the plating and provide precise corrections.
The fixator application is preferably performed with the screws
There are many alternatives to FAP. For example angle plate cor-
angulated according to the deformity. After the osteotomy par-
rections, fixator assisted nailings, gradual (fixator) or acute (
allel screws indicate the precise correction.
locking plate) wedge corrections. All of these techniques have
advantages and disadvantages. In the proximal tibia corrections we frequently use a modified
technique. We only insert 2,5 mm diameter K-wires (through
The best indications for FAP in the lower extremity are
the fixator with cannulated screws) at the opposite side from the
osteotomies with location in the diaphyseal or the proximal tib-
planned locking plate placement. Before correction the fixator is
ial region. Also in bifocal correction of tibial deformities this
removed. Parallel K- wires indicate the precise correction. FAP is
technique is suitable. This technique is not indicated when
the routine method in our hospital. The most cases are per-
lengthening of the bone is a goal of correction.
formed as proximal tibial opening wedge valgisation
osteotomies. In 50 successive patients the maximal error post-
How to perform FAP ?
operative was 3° (within the accuracy of the x-ray control). No
1. Start with deformity analysis according to Paley (Cora
secondary changes of the fragment position occurred during the
method)
healing of the osteotomy. No infection, pseudarthrosis or nerve
2. Calculate the amount of correction and translation
damage was observed.
3. Simulate postoperative fragment position
4. Fixator placement according to the deformity

REFERENCES 3. Paley D., Pfeil J. (2000) Prinzipien der kniegelenknahen Deformitätenkorrektur.

1. Geiger F., D. Sabo (2004) Tibiakopfumstellung mittels Fixateur externe. Orthopaede 29: 18-38
Orthopäde 33: 161-169 4. Pfeil J., F. Grill, R. Graf (1996) Technik der Extremitätenverlängerung,
2. Lobenhofer P., C. De Simoni, A.E. Staubli (2002) Open - wedge high – tibial Deformitätenkorrektur, Pseudarthrosenbehandlung. Springer Heidelberg Berlin
osteotomy with rigid plate fixation, Techniques in knee surgery, Vol 1, No 2 New York, Tokio
Lippincott Willliams & Wilkins

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
138 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 139

STATE OF THE ART MONOLATERAL EXTERNAL FIXATION

Richard S. Davidson, MD

1. A Brief History of Monolateral Fixation: 4. The Monolateral Solution: Multiaxial correcting monolat-
a. Initially monolateral fixators were used for static fixation eral fixation
of fractures and osteotomies. a. Two hinges were connected with planes of angulation at

SYMPOSIA GENERAL
b. Bone screws could only be applied in neuro-vascularly 90° to each other with centers of rotation 6 mm apart.
safe zones, i.e. laterally on the femur and antero-medially The primary hinge has 80°, and the secondary has 35-
on the tibia. 45° depending on the position of the primary hinge.
c. Addition of rails and threaded rods permitted compres- b. At either end, a screw and disc were attached for up to 3
sion and lengthening. cm of translation in each of two planes
d. As a cantilever system, soft tissue tension was overcome c. Depending on the location of the CORA and the hinge,
less well farther away from the rail resulting in angular the safe zone for attachment of the bone screws can be
collapse toward the rail. Initially this was dealt with by accomplished with compression/distraction clamps or
pre stressing the system (adding 5-10° of angulation in arcs (120°). No matter where the hinge (CORA) is
the opposite direction). Eventually angulating hinges placed, a safe zone can be reached with the arcs.
were added in the plane of the rail. Still these hinges d. Lengthening can be accomplished with a variety of
could only correct in the plane of the rail. Angulation in devices including compression/distraction blocks,
any other plane could not be corrected. threaded rods with traveling bone/screw blocks and
e. Traditional monolateral fixators could not correct rota- threaded rods with arc lengtheners.
tion. e. Rotation of up to 120° can be accomplished using the
f. In summary, traditional monolateral fixators were limit- rotation arc
ed to compression/distraction in the plane of the safe
5. Methods of Application: CORA Centric vs CORA
zones for bone screw fixation and small amounts of
Perpendicular
angulation in that plane.
a. The most common application will be to place the pri-
2. Ring Fixators: mary hinge over the CORA. This will accomplish angu-
a. Placing rings around the limb segment permitted wire or lar correction without lengthening. If the hinge is placed
bone screw fixation in the safe zones while still making it incorrectly, the secondary hinges and translators can cor-
possible to position the mechanical hinge over the axis rect residual deformity.
of the deformity (CORA= Center of Rotational b. If length is desired, the multiaxial correcting monolateral
Alignment). fixation can be placed in a CORA perpendicular fashion
b. Unfortunately the ring fixators were difficult to apply (on the convex side of a deformed bone on the bisector
and particularly difficult to apply about the hip and line).
shoulder.
6. Rotation and Centering
c. Ring fixators were uncomfortable for the patients.
a. The bone can be centered easily by using two screws of
d. Ring fixators were difficult for the physician to adjust or
length each of which is equal to a radius (any two radii
change.
will define the center of a circle).
3. The Rules b. The radius of each arc is added to the width of the arc,
a. Several rules were spawned by the Ilizarov method: the radius of the bone at the level of the arc (screw must
1. Anatomic assessment of deformity in two planes attach to the second cortex), and two cm for the screw
defines the CORA. clamp and wrench.
2. The bisector line defined a set of CORAs along which Bone Radius + Arc Radius +Arc thickness + 2cm for clamp
a mechanical hinge could correct the deformity. and wrench
3. Placement of the hinge along any convex side CORA
7. Rates of Lengthening in CORA Perpendicular use:
would lead to lengthening in the course of angular
a. For any given angle of correction, the rate of lengthening
correction.
is dependent on the distance from the center of the
4. Placement of the hinge along any concave CORA
hinge.
would lead to shortening in the course of angular cor-
b. Mathematical analysis can be used to calculate the fre-
rection.
quency and magnitude of the turn at the hinge in order
5. Placement of the hinge off the bisector line would
to effect the desired rate of correction.
result in translation in the course of angular correc-
tion. 8. Examples:
6. Placement of the hinge on a CORA but placing the a. Blounts (proximal tibia vara with rotation): Adult MAC,
osteotomy off the bisector line would result in local CORA perpendicular with rotation arc
translation ( A “zig-zag”) but still permit anatomic b. Tibial diahyseal fracture, nonunion: MAC, CORA centric
correction of the mechanical and anatomic axes. c. Clubfoot, distal tibial physeal disturbance, xsMAC CORA
7. Placement of the hinge in a different plane would centric
result in rotation and secondary angular deformity. d. Tibial lengthening with secondary valgus, MAC CORA
These rules are true for all deformity correction and all perpendicular
known mechanical external fixators. e. Ball and socket ankle: MAC CORA perpendicular

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
139
SYM 07:Layout 1 1/12/07 11:40 AM Page 140

REFERENCES 5. Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs: Perioperative
1. Herzenberg JE, Waanders NA. Calculating rate and duration of distraction for planning of multiapical frontal plan angular and bowing deformities of the
deformity correction with the Ilizarov technique. Orthop Clin North Am 22:601- femur and tibia. CORR 280:65-71.
61, 1991. 6. Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for
2. Loder, et al. Late onset tibia vara. JPO 11:162-7, 1991 frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 25:425-
465, 1994.
3. Noonan KT, Price CT, Sproul JT, Bright RW. Acute correction and distraction
osteogenesis for the malaligned and shortened lower extremity. J Ped Orthop. 7. Paley D. Principles of Deformity Correction. Springer-Verlag, New York, 2002.
18:178-186, 1998. 8. Price C. et al. Dynamic axial external fixation in the surgical treatment of tibia
vara. JPO 15: 236, 1995.
SYMPOSIA GENERAL

4. Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs: Perioperative

planning of uniapical angular deformities of the tibia or femur. Clin Orthop 9. Schoenecker P, et al Blount’s Disease: a retrospective review and recommenda-
280:48-64, 1992. tions for treatment. JPO 5:181-6, 1985.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
140 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 141

CORRECTION OF TIBIAL DEFORMITY USING CIRCULAR

EXTERNAL FIXATION
S. Robert Rozbruch, MD

Circular external fixation (CEF) is a powerful tool for accom- ing the deformity as well as a stabilizing the bone after the

SYMPOSIA GENERAL
plishing tibial deformity correction. Frames can use hinges to deformity has been corrected. This allows for gradual cor-
localize the apex of deformity correction. A specialized feature rection of deformities, which has great advantages over
of the hexapod frame is its virtual hinge which allows for the acute correction including lower risk of neurovascular and
simultaneous gradual correction of multiplanar deformities and soft-tissue compromise, preservation of bone stock (by not
limb lengthening through one osteotomy site. The power of the having to remove a wedge of bone), and great control over
hexapod frame lies in its precise control over final limb length final alignment. Patients with large deformities are espe-
and alignment and in its ability to correct a residual deformity. cially well served with this treatment approach.
The stability of this multi-planar circular fixator permits early • Proximal tibial osteotomy for unloading of uncompartmen-
weight bearing and provides an ideal environment for both new tal knee arthritis can be performed gradually with precision
bone formation and soft-tissue healing. Classic Ilizarov method control over the final location of the mechanical axis to
principles are followed to ensure proper frame application. The achieve ideal overcorrection.
hexapod frame with its web-based software has greatly simpli- • When deep infection is suspected, the temporary and percu-
fied the planning of oblique plane deformity correction by uti- taneous nature of the Ilizarov method without internal
lizing standard anterior-posterior and lateral radiographic hardware is useful for the treatment of infection and defor-
measurements. Correction of deformity is comprehensive by mity correction.
addressing six axis deformity parameters consisting of both • For those patients with tibial shortening the option of a
angulations and translations in the coronal, sagittal, and axial simultaneous lengthening is made possible by using CEF.
planes. • In cases where a poor soft tissue envelope is of concern, as
is often the case after severe trauma with deformity from
Advantages of using external fixation for tibial osteotomy bony malunion, large dissections can often be avoided by
and deformity correction: implementing a percutaneous osteotomy and external fixa-
A. Minimally invasive tion.
a. Pin insertion is percutaneous • When the true axis of a deformity lies in an oblique plane,
b. Osteotomy is percutaneous correction of that deformity can be very challenging with
c. Gradual correction is minimally traumatic conventional fixation methods. The hexapod frame com-
d. Minimal soft-tissue stripping puter program has greatly simplified the planning and exe-
e. More safe in situation of poor skin cution of these complex deformities with excellent results.
B. Adds dimension of time to deformity correction • When early mobilization is of primary concern, as is often
a. Have choice for either acute or gradual correction the case with large patients who need to be able to bear
b. Postoperative adjustability weight immediately for balance purposes, CEF provides
i. Improve position enough stability to support early weight bearing and range
ii. More accurate of motion exercises of the adjacent joints.
iii.Check standing radiographs during postoperative peri- • Multiple level corrections can be accomplished with this
od approach. The CEF can be used in a modular fashion to
iv. Enhance bony healing with compression address multiple levels of deformity simultaneously includ-
C. Strong stable construct ing contractures of adjacent joints.
a. Encourage weight bearing as tolerated during entire treat-
SURGICAL TECHNIQUE
ment
i. Avoid osteopenia Fibular Osteotomy
ii. Encourage bony healing Fibular osteotomy is carried out under tourniquet and is per-
D. More versatile formed at the level of the fibular deformity. A direct approach is
a. Good for complex large deformity made to the fibula through the interval between the peroneal
b. Also good for smaller deformity muscles and the soleus. Care is taken when performing the sub-
c. Not limited by intramedullary (IM) canal (as is case for periosteal dissection as the motor branch to the EHL lies close
IM rodding) to the anteromedial border of the fibula. The soft tissue is pro-
E. Avoid Shortening tected with Hohman retractors exposing the fibular diaphysis. If
a. Avoid closing wedge corrections a lengthening is needed then the fibula is predrilled with an
b. Opening wedge correction adds length Ilizarov wire and the osteotomy is completed with a narrow
c. Option of adding more length if needed osteotome. If performing an angular correction with minimal
F. Avoid internal fixation lengthening, then an oblique osteotomy is made with an oscil-
a. No painful hardware lating saw and copious irrigation as this cut will allow the fibu-
b. No need for hardware removal lar bone ends to slide and shorten. At times we will resect a
small section of the fibula if significant fibular shortening is
Indications:
anticipated or if early fibular consolidation is anticipated. The
• CEF is indicated for any tibial deformity correction.
fascia is left open and the skin is closed in layers. The tourniquet
Although other fixation techniques have been successful at
is then deflated for the remainder of the operation.
stabilizing deformities once they been corrected, the CEF
has the distinct advantage of providing a means of correct-
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
141
SYM 07:Layout 1 1/12/07 11:40 AM Page 142

Proximal Ring Application The six struts are attached to the proximal ring and tightened.
The frame in then applied to the limb before creating the tibial The struts are secured to the distal ring without introducing any
osteotomy. The technique that we use to apply the hexapod tension or compression forces to the system. Free rotation of the
frame is the “rings first” method. We favor this technique struts should be possible as the shoulder bolts spin through the
because it frees the rings for ideal placement on the leg with ring. The strut lengths are recorded.
regard to the soft tissues. The tourniquet is not recommended
for this portion of the surgery as it is felt that adequate blood Foot Ring Application
flow is needed to cool wires and drills as they pass through the At times the addition of a foot ring will be required. The most
SYMPOSIA GENERAL

bone and soft tissues. A common location for tibial osteotomy common indication to include a foot ring while correcting a tib-
used for deformity correction is in the proximal tibial metaph- ial deformity is to treat an equinus contracture of the ankle
ysis just below the tibial tubercle. The following technique will joint. Hinges placed along the ankle’s oblique axis will allow for
illustrate the method we use for proximal tibial osteotomy. The constrained gradual restoration of a plantargrade foot while
same frame mounting and osteotomy principles can be applied protecting the articular surface. The foot is also included in cases
at any level of the tibia. Using the fluoroscopic AP projection a of very distal tibial osteotomies where adequate stability cannot
smooth 1.8mm Ilizarov wire is advanced across the proximal be obtained using the distal tibial ring alone. The addition of a
tibial metaphysis from lateral to medial perpendicular to the foot ring greatly increases the stability of the distal ring block. As
proximal tibial mechanical axis. The wire should start 14mm healing progresses, the foot ring is removed in the office to
distal to the lateral tibial plateau in order to remain out of the dynamize the osteotomy. If an equines deformity had occurred
joint capsule. Once this wire has been placed the proximal ring as the result of a prior unrecognized anterior compartment syn-
is centered on the leg, and the wire is tensioned. We prefer to use drome, then great caution must be exercised in placing wire fix-
a 2/3 ring proximally to accommodate posterior leg swelling ation through an anterior compartment that contains necrotic
and allow proximal knee flexion. The ring is held in a position muscle tissue as this can lead to severe infection. The open sec-
orthogonal to the mechanical axis of the tibia in the sagittal tion of the foot ring is closed with a half ring or a connecting
plane. A second wire is placed through the fibular head exiting rod. The ring is then attached to the foot with two crossing
the anteromedial tibia. The fibular wire is needed when plan- oblique calcaneal wires and one midfoot wire.
ning a lengthening or a large rotational correction. When plac-
ing wires through the fibular head great care is taken to avoid Tibial Osteotomy
damaging the common peroneal nerve. The wire is then To carry out the tibial osteotomy, the struts are detached from
advanced in a normal fashion always watching the foot for the proximal ring. The tibial osteotomy should be made distal
motion. Once the wire tip has crossed through the leg and has to the tibial tubercle to prevent involvement of the extensor
exited the skin, the drill is removed and the wire is tapped mechanism, but it should be proximal enough that it courses
through the remainder of the way. A half pin is placed antero- through cancellous metaphyseal bone to ensure reliable regen-
lateral at Gerdy’s tubercle in a posteromedial direction. An addi- erate formation. The osteotomy we use is a percutaneous drill-
tional half pin is placed from an anteromedial starting point hole technique. With the leg well supported on bumps, the C-
and inserted in a posterolateral direction. We advocate the use arm is positioned for a lateral view of the proximal tibia. A 1cm
of hydroxyapatite coated half pins for this procedure. These incision is made over the tibial crest just distal to the tibial
pins have been associated with a decreased incidence of loosen- tubercle. The incision is carried down through the periosteum
ing and subsequently the perception of a lower rate of pin site and onto the crest. A 5mm elevator is used to gently raise a por-
infection. tion of the periosteum on either side of the tibia. The cortex is
predrilled in multiple directions along the same plane with a
Mounting Parameters 4.8mm drill. Lateral fluoroscopy will help prevent passing the
Once the proximal ring is secured, the mounting parameters are drill or osteotome into the posterior compartment as it travers-
calculated. The mounting parameters are a set of measurements es the posterior tibial cortex. A 5mm osteotome is advanced
that inform the computer of the location of the reference ring through the cortical bone of the tibia’s medial and lateral cor-
with respect to the origin. Although any ring can be selected to tices. When the osteotome is fully seated through the width of
be the reference ring, the ring closest to the osteotomy is typi- the bone and is engaging the posterior cortex it is twisted with a
cally selected to be the reference ring. The position of the cen- 14mm wrench producing an audible crack as the posterior cor-
ter of the ring with respect to the origin in the coronal, sagittal, tex fails. The distal ring is gently externally rotated with respect
and axial planes is measured in millimeters and recorded. to the proximal ring to ensure that the osteotomy is complete.
The bone ends are reduced to their pre-osteotomy position
Distal Ring Application relieving stress on the periosteum and decreasing bleeding. The
Attention is then turned to the distal ring. Some thought should struts are reattached to the rings at their previously measured
be given to determining the optimal distance between the rings. lengths stabilizing the osteotomy site in a nondisplaced posi-
This will help minimize strut changes which are an inconven- tion. The epidural is discontinued in the immediate post oper-
ience to the patient and the surgeon. Typically medium struts ative period to avoid masking early signs of compartment syn-
are used, and they are set in the middle length position drome, although we have not yet experienced any cases of com-
(145mm). A medial face wire is advanced from lateral to medi- partment syndrome using this technique.
al across the tibia orthogonal to the long axis of the tibia. Care
must be taken not to generate heat while advancing the wire Post Operative Care
through this diaphyseal bone. Frequent pauses are prudent. The Patients are admitted to the hospital for two to three days. The
distal ring is centered on the leg and fastened to the wire. The patients receive intravenous antibiotics for twenty-four hours
wire is tensioned in the usual fashion. Two or three additional and are then switched to oral antibiotics. The dressings are
half pins are inserted proximal and distal to the distal ring, removed on post operative day two. Nurses teach proper daily
preferably in different planes, yielding a total of three or four pin care consisting of a mixture of half normal saline and half
points of fixation distally. Alternatively, a ring block can be used hydrogen peroxide applied to the pin sites with sterile cotton
that consists of 2 rings and a total of 4-5 points of fixation. swabs. Pins and wires are wrapped with Xeroform dressings at
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
142 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 143

the skin. Patients are allowed to begin showering on the fourth on the amount of correction and lengthening that is needed. In
post operative day. They are instructed to wash the frame and general, adult patients can expect to need the frame from 1-
pin sites with antibacterial soap as an adjuvant form of pin care. 2months/cm of lengthening. Most angular corrections are com-
Non-steroidal anti-inflammatory medications are avoided in all pleted after 2-4weeks of adjustments. The total time in the frame
osteotomy patients for fear of adverse affects on bone forma- for deformity corrections is usually 3-4 months.
tion. The patients are discharged on oral antibiotics for ten days
and oral pain medication. Recognition of early pin tract infec- Fixator Removal
tion is taught. Should this occur, oral antibiotics are promptly Fixators are removed when patients are ambulating without

SYMPOSIA GENERAL
prescribed to the patient. Patients return to the office ten days pain or the use of an assistive device and when callus is seen on
post operatively where sutures are removed and they are edu- three cortices around the osteotomy site. This varies tremen-
cated on how to perform strut adjustments. Patients are seen dously depending on what goals are being accomplished. We
every two weeks during this adjustment period and then once prefer to remove the frames in the operating room. The removal
monthly during the consolidation period. The success of any of HA coated pin can be uncomfortable and bloody. We choose
gradual correction system is founded in the patient’s ability to to curette all half pins sites in an effort to keep pin tracts clean
participate in their own care. Patients are responsible for per- for possible future use of internal implants. Transfixion wire
forming their own strut adjustment three times daily at the out- sites are not debrided unless there is concern over a specific site.
set of treatment. Patients need to be seen frequently during the At the time of frame removal bony union and maturation of the
adjustment period to avoid errors. regenerate may be evaluated with a stress test under C-arm flu-
oroscopy. The struts are removed and the rings manually com-
Correction of the deformity begins after a latency period of 7-10
pressed and distracted looking for motion at the osteotomy site.
days. The web-based program is used to generate a daily sched-
A lack of consolidation will require replacement of the struts
ule for strut adjustments that the patient will perform at home.
and prolonging the time in the frame. Once the fixator is
The computer requires the input of basic information including
removed patients are placed into a hinged knee brace with full
the limb laterality, the deformity parameters (determined from
motion or a short leg cast depending on the site of the osteoto-
pre-operative planning), the size of the rings and length of struts
my and clinical needs. They are allowed partial weight bearing
used, the mounting parameters (measured during frame appli-
for two weeks then progress to full weight bearing thereafter.
cation), and rate of daily adjustment. Additionally a structure at
risk is selected and entered into the program (in terms of the
Pitfalls:
distance from the origin) to assure soft tissue protection during
• Incomplete osteotomy will often lead to a premature con-
the gradual correction. For valgus producing osteotomy the
solidation.
structure a risk is the medial soft tissues as they are in the con-
• Proper pin and wire insertion technique, including strict
cavity of the correction and have the greatest distance to travel.
adherence to anatomic safe zones, is paramount to the suc-
Similarly, if correcting a valgus deformity, then one might
cess of this technique. Great care must be taken to avoid
choose the peroneal nerve as the structure at risk. Using this
thermal necrosis which will lead to loosening of fixation,
information a clear and simplified prescription is created for the
pin infection, and patient discomfort
patient to follow every day. We prescribe that struts 1 and 2 be
• Choosing the osteotomy site requires careful consideration
turned in the morning, struts 3 and 4 in the afternoon, and
of two independent goals: 1) maximizing healing potential
struts 5 and 6 in the evening for a total movement of one mil-
of the osteotomy and 2) re-establishing proper alignment,
limeter per day. The duration of the adjustment phase depends
not necessarily an anatomic reduction of the deformity.

REFERENCES 7. Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative
1. Rozbruch SR, Herzenberg JE, Tetsworth K, et al. Distraction osteogenesis for planning of uniapical angular deformities of the tibia or femur. Clin Orthop
nonunion after high tibial osteotomy. Clin Orthop 2002;394:227-35 1992;280:48

2. Rozbruch SR, Helfet, DL, Blyakher A: Distraction of Hypertrophic Nonunion of 8. Paley D. Principles of Deformity Correction. (ed) Herzenberg JE. Springer-Verlag
Tibia with Deformity Using Ilizarov/Taylor Spatial Frame. Archives of BerlinHeidelberg 2002;479-507
Orthopaedic and Trauma Surgery. 122;295-298, 2002. 9. Reid JS, Vanslyke M, MoultonMJR, et al. Safe placement of proximal tibial transfix-
3. Rozbruch SR. Posttraumatic reconstruction of the ankle using the Ilizarov ion wires with respect to intracapsular penetration. Orthop Trans 1997;21:574-575
method. HSSJ 2005;1(1):68-88 10. Savarino L, Stea S, Granchi D, et al. X-Ray diffraction of bone at the interface
4. Fragomen AT, Ilizarov S, Blyakher A, Rozbruch SR. Proximal tibial osteotomy for with hydroxyapatite-coated versus uncoated metal implants. J Mater Sci Mater
medial compartment osteoarthritis of the knee using the Ilizarov/ Taylor Spatial Med 1998;9(2):109-15
Frame. Tech Knee Surg 2005;4(3):173-85 11. Ilizarov GA. Transosseus osteosynthesis. Theoretical and clinical aspects of the
5. Feldman DS, Shin SS, Maden S. Correction of tibial malunion and nonunion regeneration and growth of tissue. (Ed) Green S. Springer-Verlag Berlin
with six-axis analysis deformity correction using the Taylor Spatial Frame. J Heidelberg 1992:63-136
Orthop Trauma. 2003 Sep;17(8):549-54. 12. Ilizarov GA. The influence of blood supply and loading upon the shape forming
6. Sen C, Kocaoglu M, Eralp L. The advantages of circular external fixation used in processes in bones and joints, In: Transosseus osteosynthesis. Theoretical and
high tibial osteotomy (average 6 yrs. Follow-up). Knee Surg Sports Traumatol clinical aspects of the regeneration and growth of tissue. (Ed) Green S. Springer-
Arthrosc 2003;11:139-144 Verlag Berlin Heidelberg 1992:257-278

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
143
SYM 07:Layout 1 1/12/07 11:40 AM Page 144

WHAT EVERY RESIDENT SHOULD KNOW

SYMPOSIA HAND/WRIST

ABOUT HAND SURGERY (EE)

Moderator: David Bozentka, MD, Philadelphia, PA (n)

The session will be organized by the ASSH Resident Education Curriculum Task Force. The
main objective will be to introduce the Orthopedic Surgery Resident to the various clinical
problems treated by the hand and upper extremity surgeon. A total of six cases will be
presented to three senior members of the ASSH. Questions will be posed to the panel
regarding pearls in the workup and treatment of the clinical scenarios. Each case will
conclude with a concise review of the subject including the information that a resident
should know while preparing for the in-training and board exams.

I Introduction
Case Presentations

II Richard Gelberman MD, Saint Louis, MO (n)

Presenter: Martin Boyer MD, Saint Louis, MO (d, e – OrthoHelix, Inc)
Flexor tendon with concomitant digit nerve injury
Presenter: Kimberly Mezera MD, Dallas, TX (n)
Distal radius fracture

III. Peter Stern M.D.

Presenter: David Bozentka MD, Philadelphia, PA (n)
Scaphoid fracture
Presenter: Pedro Beredjiklian MD, Philadelphia, PA (n)
PIP fracture dislocation

IV. James W. Strickland, MD, Carmel, IN (n)

Presenter: Paul Binhammer MD, Toronto, ON Canada (n)
Dorsal hand soft tissue coverage
Presenter: Charles Goldfarb MD, Saint Louis, MO (n)
Congenital hand deformity

V. Questions and Answers / Conclusion

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
144 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 145

CARPAL BONE FRACTURE

David Bozentka, MD

Scaphoid fracture CT scans valuable in confirming healing

Anatomy Average healing scaphoid factures by location

SYMPOSIA HAND/WRIST
Boat shaped bone 100% distal pole fractures
Cartilage surface 80-90% waist fractures
Blood supply 60-70% proximal pole fractures
Dorsal scaphoid branch radial artery – dorsal ridge delay dx more than 28 days increase nonunion
scaphoid rate
Supplies 70 to 80% of bone including proximal Nonunion
pole Sclerosis, cyst formation
Volar carpal branch of radial artery Humpback deformity
Supplies 20 to 30% of bone AVN
Treatment Treatment
Snuffbox tenderness Bone stimulator
Immobilization thumb spica Non-displaced or angulated – percutaneous screw
Repeat x-rays fixation
MRI or CT to rule out fx Collapse deformity – ORIF corticocancellous bone
Non-displaced fractures graft
Nonoperative treatment Scaphoid nonunion with mild arthritic changes
Long arm cast 6 weeks involving sharpening of the radial styloid is treated
Followed by short arm cast till healed with ORIF, bone graft and radial styloidectomy*
Proximal pole fractures my require 20 weeks to AVN – local vascularized bone graft
heal SNAC wrist – arthritis
Surgical treatment for fractures not healed by 20 All scaphoid nonunions will develop DJD by 5-10 yrs
wks if untreated
Operative treatment Proximal Row Carpectomy – PRC
Percutaneous screw fixation Scaphoid excision and four-corner fusion
Displaced fractures
Hamate fractures
Open reduction internal fixation
Hook of hamate fracture
Compression screw fixation
Direct trauma to hypothenar region
Central screw placement improves mechanical
Golf, hockey, baseball,
properties
Point tenderness hook
K-wire fixation
Ulnar nerve symptoms
Bone graft
Following normal x-rays, CT is the most cost effective
Corticocancellous for hump back deformity
diagnostic test*
Volar approach
Cast immobilization for acutely diagnosed fractures
Waist to distal pole fractures
Nonunion
Dorsal approach
Risk of FDP tendon rupture with nonunion*
Proximal pole fractures to waist fractures
Treatment – excision ununited fragment
Fracture healing
Assessment by x-ray difficult

REFERENCES 4. Joseph F. Slade, III, William B. Geissler, Andrew P. Gutow, and Greg A. Merrell
1. Chou KH, Sarris I, Papadimitiou NG, and Sotereanos D: Fractures of the hand Percutaneous Internal Fixation of Selected Scaphoid Nonunions with an
wrist and forearm axis. In Beredjiklian PK, Bozentka DJ, eds: Review of Hand Arthroscopically Assisted Dorsal Approach, J. Bone Joint Surg. Am., 2003; 85: 20
Surgery, 1st ed. Philadelphia, Elsevier Inc, 2004, pp101-125. - 32.

2. Trumble TE, Salas P, Barthel T, Robert KQ III: Management of scaphoid 5. GR Mack, MJ Bosse, RH Gelberman, and E Yu: The natural history of scaphoid
nonunions. JAAOS, 11: 380-391, 2003. non-union, J. Bone Joint Surg. Am.,1984; 66: 504 - 509.

3. Charles D. Bond, Alexander Y. Shin, Mark T. McBride, and Khiem D. Dao 6. H Gellman, RJ Caputo, V Carter, A Aboulafia, and M McKay: Comparison of
Percutaneous Screw Fixation or Cast Immobilization for Nondisplaced Scaphoid short and long thumb-spica casts for non-displaced fractures of the carpal
Fractures, J. Bone Joint Surg. Am., 2001; 83: 483. scaphoid, J. Bone Joint Surg. Am., 1989; 71: 354 - 357.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
145
SYM 07:Layout 1 1/12/07 11:40 AM Page 146

CONGENITAL ANOMALIES OF THE HAND

Charles Goldfarb, MD

Classification Zig – zag incisions

Failure of formation - longitudinal and transverse Protect neurovascular bundles
SYMPOSIA HAND/WRIST

Failure of differentiation Skin graft common

Duplication Thumb anomalies****
Overgrowth Hypoplasia
Undergrowth I Small thumb
Constriction bands II Small thumb with deficient thenar muscles, small
Generalized skeletal abnormalities first web space, unstable MCP joint
Treatment includes MCP stabilization and ten-
Failure of formation
don transfer for thumb abduction (ADM or FDS
Transverse
of ring finger)
Congenital amputations
III Tendon and skeletal abnormalities*
Most common site proximal third forearm
CMC stable – reconstruction
Unilateral, sporadic, rarely associated with other
CMC unstable – pollicization
anomalies
The main determinate of ablation or reconstruc-
Prosthesis when independent sitting (6 to 9 months)
tion of a hypoplastic thumb is the absence or
Longitudinal
presence of a stable CMC joint*
Radial deficiency – “radial club hand”
IV Pouce flottant – pollicization
Pre-axial deficiency
V Absent thumb - pollicization
Classification
Digit anomalies****
I short distal radius
Camptodactyly - Flexion deformity**
II Hypoplastic radius
Abnormal lumbrical/ FDS insertion
III Partial absence
Nonoperative treatment including splinting prior to
IV Complete absence - most common variant
consideration of surgical intervention
Treatment
Clinodactyly*
Types I, II: Soft tissue balancing/ possible radius
Lateral deviation of digit
lengthening
Surgical treatment rare as functional problems
Types III, IV: Centralization of carpus on ulna
uncommon
Associated syndromes
Kirner’s deformity*
Holt–Oram – heart defects, most common cardiac
Volar curvature distal phalanx
septal defect
Symphalangism
TAR- Thrombocytopenia with absent radius
Failure of finger IP joint development
Vacterl
Fanconi anemia Duplication*
Ulnar Deficiency Polydactyly
Marked less common than RLD Pre-axial, central, post-axial
Associated conditions include elbow deficiency and Post-axial most common*
other musculoskeletal abnormalities but not systemic Autosomal dominant inheritance*
conditions (i.e., heart, kidneys normal) Most common in African American population
Surgery most common for hand anomalies Excision in preschool years
Central deficiency - Cleft hand Only soft tissue – ligation at birth
Longitudinal deficiency of central rays of the hand Normal appearing digit – excision preserving vital
Typical Cleft hand structures
Bilateral, familial, syndactyly common, Thumb duplication*
Atypical Cleft hand (Now known as symbrachydactyly) 0.08 in 1000 live births
Unilateral, spontaneous, syndactyly rare male to female ratio 2.5 : 1
Poland’s syndrome** sporadic with random inheritance
Symbrachydactyly and associated deficiency of often with hypoplasia of thumb radial > ulnar
the pectoralis major Wassell Classification**
I Bifid distal phalanx
Failure of differentiation***
II Duplicate distal phalanx
Syndactyly
III Bifid proximal phalanx
Most common congenital hand anomaly – 1 in 2000
IV Duplicate proximal phalanx
live births*
V Bifid metacarpal
Most common involving long and ring fingers
VI Duplicate metacarpal
Complete vs incomplete (degree of skin involvement)
VII Tri-phalangeal thumb
Simple vs complex (+/- bone involvement)
Treatment
Apert’s syndrome*
Surgical treatment 6 to 9 months of age
Acrosyndactyly and mental retardation
Excision
Surgery early and completed by school age
If extra digit is a small excrescence: rare

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
146 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 147

Excision with reconstruction of joint Relentless and grotesque enlargement requires amputa-
Most common scenario: radial thumb is excised tion
and ulnar thumb is stabilized with or without
Constriction band syndrome*
osteotomies to align
Central digits most affected
Combination of symmetric digits
Associated anomalies in 40%
Major parts of the two digits merged side to side
Club foot most common*
Bilhaut-Cloquet*

SYMPOSIA HAND/WRIST
Surgical treatment
Combination of asymmetric digits
Severe banding (fingers, calf region)
Most of one digit retained augmented by parts of
Release and z-plasty to prevent recurrence
resected digit
Syndactyly (typically fenestrated)
Overgrowth Release with or without skin grafts
Macrodactyly – overgrowth of all structures of the involved Madelung’s deformity**
digit Abnormal growth of volar and ulnar distal radius epiphysis
Radial fingers more commonly involved Most often in girls and bilateral
Treatment Appearance of short radius ulnar volar tilt distal radius and
Debulk skin and fat Autosomal dominant trait
Epiphysiodesis when size of finger is same as parent
of the same sex

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
147
SYM 07:Layout 1 1/12/07 11:40 AM Page 148

COMPRESSIVE NEUROPATHIES IN 2007 (Q)

SYMPOSIA HAND/WRIST

Moderator: Robert M. Szabo, MD, Sacramento, CA (n)

Major nerve compression syndromes of the upper extremity including controversies and
treatment failures will be discussed with audience participation in case presentations.

I. Carpal tunnel, pronator and anterior interosseous nerve syndromes

Robert M. Szabo, MD, Sacramento, CA (n)

II. Cubital and ulnar tunnel syndromes

Richard H. Gelberman, MD, Saint Louis, MO (n)

III. Radial tunnel, posterior interosseous and Wartenburg’s syndrome

Peter J. Stern, MD, Cincinnati, OH (n)

IV. Failed carpal and cubital tunnel syndrome

Ghazi M. Rayan, MD, Oklahoma City, OK (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
148 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 149

MEDIAN NERVE COMPRESSION NEUROPATHIES

Robert M. Szabo, MD

Specific compression syndromes of the median nerve are lized to try to localize the site of median nerve compression.
known in the proximal forearm and at the wrist. Carpal tunnel Pain or paresthesias produced by resisted forearm supination in

SYMPOSIA HAND/WRIST
syndrome is the best known and most common, but pronator combination with resisted elbow flexion beyond 120 degrees
teres syndrome and anterior interosseous nerve syndrome are implicates compression at the bicipital aponeurosis 1,2,10.
also clinically significant. Attention to the controversial aspects Paresthesias resulting from resisted forearm pronation while the
of these conditions with regards to etiology and treatment is dis- elbow is slowly extended from full flexion suggest compression
cussed. between the two heads of the PT 2,10,11. Resisted proximal
interphalangeal joint flexion of the middle finger producing
Pronator Syndrome & Anterior Interosseous Nerve Palsy paresthesias in the radial three digits suggests entrapment under
Seyffarth first coined the term pronator syndrome, in his report the fibrous origin of the FDS 3,10.
on the nonoperative management of 17 patients in 1951, to
In 1948, Parsonage and Turner reported 6 patients with paraly-
describe a compression neuropathy of the median nerve as it
sis of the flexor pollicis longus (FPL) and the flexor digitorum
passes through the pronator teres 1. Johnson and Spinner char-
profundus (FDP) to the index finger, and attributed the condi-
acterized this syndrome based on observations in 103 operative
tion to an anterior horn cell lesion 12. Kiloh and Nevin, in
decompressions 2,3. Pronator syndrome now is a term used to
1952, reported an “isolated neuritis” of the anterior
describe a pain syndrome resulting from compression of the
interosseous nerve (AIN) in two patients with these findings 13.
median nerve by any structure in the proximal forearm and
In 1965, Fearn and Goodfellow were the first to propose
elbow. In 1848 and 1854, John Struthers wrote about sites of
mechanical compression as the cause of the syndrome; they
compression of the median nerve in the upper extremity. He is
suggested that it be treated surgically 14. The debate continues
best known for describing entrapment of the median nerve by a
as to whether AIN is neuritis, compression neuropathy, or both.
ligament (the ligament of Struthers) from a supracondylar
process to the medial epicondyle of the humerus 4. In the fore-
Carpal Tunnel Syndrome
arm, the median nerve can be compressed by the pronator teres,
Although the term, “carpal tunnel syndrome” was termed by
the flexor superficialis arch, or the bicipital aponeurosis (lacer-
Moersch in 1938 15, the condition was not widely recognized
tus fibrosis) 3. Several accessory and variant muscles have been
until an article by Phalen in 1951 16. It is now estimated that
noted as compressing structures, including Gantzer’s muscle, an
one million adults in the United States are diagnosed with CTS
accessory head of the FPL, the palmaris profundus, and the flex-
each year 17. Medical costs resulting from CTS exceed $1 billion
or carpi radialis brevis. Gantzer’s muscle was present in to 52%
per year, and over 200,000 surgical procedures are performed
5 of cadavers studied. It is innervated by the AIN, arises from the
annually 18. Some members of the medicolegal community,
medial epicondyle 85% of the time, and has a dual origin from
popular media, and insurance industry have incorporated cer-
the epicondyle and coronoid process of the ulna in the remain-
tain compressive neuropathies into a group of disorders known
der 6.
as cumulative trauma disorders or repetitive stress injuries.
Clinical symptoms of pronator syndrome include forearm pain There is little scientific evidence supporting the concept that CTS
as well as paresthesias and hypoesthesia in the cutaneous distri- is caused by work. One problem is that cases of occupational
bution of the median nerve, i.e., the thumb, index, long, and CTS believed to be caused by work activities are almost always
radial half of the ring finger. Physical examination reveals ten- accompanied by other upper extremity symptoms that are poor-
derness on palpation of the median nerve in the proximal fore- ly characterized and difficult to diagnose 19. It has been shown
arm. The PT muscle can be tender, firm, or appear to be enlarged that 81% of the electrophysiological slowing in the median
3. There is no weakness of the median-innervated intrinsic or nerve was due to body mass index, age, and the wrist depth/
extrinsic muscles. Palpation of the medial humeral condyle and width ratio, whereas only 8% was due to job-related factors 20.
distal diaphysis may reveal a bony prominence, the supra- Gerr and Letz finally concluded that “CTS is closely correlated
condylar process. AP, lateral, and oblique x-rays of the elbow with health habits and life-style but is only peripherally related
should be obtained to rule out its presence. The absence of a to workplace activities 21. Phalen’s wrist flexion test, direct com-
supracondylar process does not rule out the existence of a liga- pression of the median nerve, Tinel’s nerve percussion test 22
ment of Struthers and entrapment at this site, nor does its pres- and a hand diagram in which the patient marks on an outline
ence ensure that the ligament of Struthers is indeed the site of of the dorsal and palmar aspects of the hand the location of
compression - this is a very rare site of entrapment 7. Threshold pain, numbness, or tingling are easily performed clinical tests.
testing with Semmes-Weinstein monofilaments may reveal Clinical history and physical exam including provocative tests
decreased sensibility over the distribution of the median nerve, are more easily performed than electrodiagnostic studies, and
including the thenar eminence. they are the most appropriate diagnostic tools in the ambulato-
ry setting 22.
Phalen’s wrist flexion test should be negative, but may be posi-
tive 8,9. Tinel’s percussion test, in which the median nerve in Despite the advanced state of medical knowledge and technol-
the proximal forearm is percussed, elicits tingling and paresthe- ogy today, many of the treatment modalities utilized still
sias proximal to the wrist in contrast to CTS, where this test is depend on anecdotal reports. Standardization of results, resolu-
positive distally at the wrist. The pronator compression test has tion of so-called controversies, and advancement in practice can
been found to be an accurate and dependable physical sign in only come through the broadened use of evidence-based medi-
the diagnosis of pronator syndrome. Manual compression of cine. There are but scattered studies that guide our current treat-
the median nerve at or near the pronator muscle usually repro- ment recommendations. In one of these, Gerritsen et al
duced paresthesias in the median-innervated distribution with- reviewed 14 randomized clinical trials for the surgical treatment
in 30 seconds 8,10. Several provocative maneuvers can be uti- of carpal tunnel syndrome and concluded that none of the alter-
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
149
SYM 07:Layout 1 1/12/07 11:40 AM Page 150

natives to standard open carpal tunnel release provided better tunnel release with and without adjunctive neurolysis or
relief of symptoms. They concluded that standard open carpal epineurotomy. They found that patients who underwent such
tunnel release is still the preferred method of treatment for CTS procedures tended to have poorer global outcomes than those
since it is just as effective as the alternatives, but is technically who did not, and suggested that neural surgery beyond release
less demanding and therefore subjects the patient to a lower risk is potentially harmful for most patients with carpal tunnel syn-
of complications and lower costs 23. Recently, Chapell et al per- drome 24.
formed a meta-analysis on the results of eight studies that com-
SYMPOSIA HAND/WRIST

pared the global outcomes of patients who underwent carpal

REFERENCES 12. Parsonage MJ, Turner JW. Neuralgic amyotrophy: the shoulder-girdle syndrome.
1. Seyffarth H. Primary myoses in the m. pronator teres as cause of the n. medianus Lancet 1948;974-978.
(the pronator syndrome). Acta Psychiatr Scand [Suppl] 1951;74:251-254. 13. Kiloh LG, Nevin S. Isolated neuritis of the AIN. Br Med J 1952;1:850-851.
2. Johnson RK, Spinner M, Median nerve compression in the forearm: the pronator 14. Fearn CBDA, Goodfellow JW. Anterior Interosseous Nerve Palsy. J Bone Joint
tunnel syndrome, in Nerve Compression Syndromes — Diagnosis and Surg 1965;47B:91-93.
Treatment, R.M. Szabo, Editor. 1989, Slack Inc.: Thorofare, New Jersey. p. 137- 15. Moersch F. Median thenar neuritis. Proc Staff Meet Mayo Clin 1938;220-222.
151.
16. Phalen G. Spontaneous compression of the median nerve at the wrist. JAMA
3. Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syndrome 1951;145:1128-1133.
in the proximal forearm. J Hand Surg 1979;4A:48-51.
17. Michelsen H, Posner M. Medical history of CTS. Hand Clin 2002;18:257-268.
4. De Jesus R, Dellon AL. Historic origin of the "Arcade of Struthers". J Hand Surg
2003;28A:528-31. 18. Patterson JD, Simmons BP. Outcomes assessment in carpal tunnel syndrome.
Hand Clin 2002;18:359-63, viii.
5. al-Qattan MM. Gantzer's muscle. An anatomical study of the accessory head of
the flexor pollicis longus muscle. J Hand Surg 1996;21B:269-70. 19. Szabo R, Entrapment and compression neuropathies, in Green's operative hand
surgery, D. Green, Editor. 1999, Churchill Livingstone: Philadelphia.
6. Doyle J, Botte, MJ, Surgical anatomy of the hand & upper extremity. 2003,
Philadelphia: Lippincott Williams & Wilkins. 407-460. 20. Nathan PA, Keniston RC, Myers LD, Meadows KD. Obesity as a risk factor for
slowing of sensory conduction of the median nerve in industry. A cross-sectional
7. Halikis M, Taleisnik, J, Szabo, RM, Compression neuropathies of the upper and longitudinal study involving 429 workers. J Occup Med 1992;34:379-83.
extremity, in Chapman's orthopaedic surgery, M. Chapman, Editor. 2000,
Lippincott Williams and Wilkins: Philadelphia. 21. Gerr F, Letz R. Risk factors for carpal tunnel syndrome in industry: blaming the
victim? J Occup Med 1992;34:1117-9.
8. Olehnik WK, Manske PR, Szerzinski J. Median nerve compression in the proxi-
mal forearm. J Hand Surg 1994;19A:121-6. 22. Szabo RM, Slater RR, Jr., Farver TB, Stanton DB, Sharman WK. The value of diag-
nostic testing in carpal tunnel syndrome. J Hand Surg 1999;24A:704-14.
9. Hartz CR, Linscheid RL, Gramse RR, Daube JR. The pronator teres syndrome:
Compressive neuropathy of the median nerve. J Bone Joint Surg 1981;63A:885- 23. Gerritsen A, Uitdehaag B, van Geldere D, Scholten R, de Vet H, Bouter L.
891 Systemic review of randomized clinical trials of surgical treatment for carpal tun-
nel syndrome. Br J Surg 2001;88:1285-1295.
10. Spinner M, Management of nerve compression lesions of the upper extremity, in
Management of peripheral nerve problems, G. Omer, Spinner, M, Editor. 1980, 24. Chapell R, Coates V, Turkelson C. Poor outcome for neural surgery (epineuroto-
Saunders: Philadelphia. p. 562. my or neurolysis) for carpal tunnel syndrome compared with carpal tunnel
release alone: a meta-analysis of global outcomes. Plast Reconstr Surg
11. Spinner M, Injuries to the major branches of peripheral nerves of the forearm. 2 2003;112:983-90; discussion 991-2.
ed. Vol. 1. 1978, Philadelphia: W.B. Saunders Company. 278.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
150 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 151

CUBITAL TUNNEL AND ULNAR TUNNEL SYNDROMES

Richard H. Gelberman, MD

I. Cubital Tunnel Syndrome d. Identification of medial intramuscular sep-

A. Scientific studies regarding cause tum

SYMPOSIA HAND/WRIST
1. Cubital tunnel area decreases 42% with elbow flexion. i. Excision of medial intramuscular septum
2. Ulnar nerve cross-sectional area decreases 36%. a. Identification and preservation of inferi-
3. The nerve becomes taut with flexion. or ulnar collateral artery
4. Interstitial pressure begins to rise significantly at 110° b. Decompression of cubital tunnel and
flexion. division of Osborne’s ligament
B. Symptoms/signs c. Creation of fascial flap (1.5 by 1.5 cm)
1. Ulnar paresthesias. with quadrilateral base
2. Percussion test. d. Post-operative rehabilitation
3. Nerve hypermobility. i. Burn gauze dressing
4. Elbow flexion test. ii. Posterior orthoplast splint in 30 degrees flexion
C. Compression sites (6) iii.Early active motion
1. Medial head triceps. e. Submuscular transposition.
2. Medial intramuscular septum. i. Indications: Thin patients and those with failed
3. Arcade of Struthers. subcutaneous transpositions.
4. Cubital tunnel. ii. Rehabilitation more extensive.
5. Flexor carpi ulnaris origin. f. Endoscopic deepening of the cubital tunnel (experi-
D. EMG mental).
1. Obtained in all patients preoperatively. 6. Conclusions:
2. Reduced conduction velocity by 30 to 50% (<45 a. Anterior transposition using a fasciodermal sling
m/sec). leads to a high degree of satisfaction and relief of
E. Treatment primary symptomatology in most patients.
1. Conservative b. Immediate mobilization following anterior subcu-
a. Avoid overhead weights taneous transposition leads to no significant
b. Avoid direct pressure improvement in quantitative secondary outcomes.
c. Habit of extending elbow c. Immediate postoperative active range of motion
d. Nocturnal splint improves rehabilitation and results in earlier return
2. Operative to work and ADL’s.
a. In situ decompression.
II. Ulnar Tunnel Syndrome
i. Indicated when nerve compression is at
A. Anatomy
Osborne’s fascia.
1. Zone 1 – 50% motor; 50% motor and sensory
ii. Consistent failure rate: 30%.
a. 19 ganglions
b. Medial epicondylectomy.
b. 13 fractures
i. Most popular technique currently.
c. 3 anomalous muscles
ii. Risks injury to medial collateral ligament.
2. Zone 2 – All motor
c. Subcutaneous transposition.
a. 21 ganglions
i. Eaton technique of subcutaneous transposition
b. 5 fractures
with fascial sling
c. 3 thickened fibrous arches
a. Long medial incision across surgeon’s initials
3. Zone 3 – All sensory
b. Identification of medial antebrachial cuta-
a. 5 thrombosis ulnar artery
neous nerve (4 cm above to 4 cm below
b. 2 anomalous muscles
medial epicondyle).
B. Method of operative release
c. Division of Arcade of Struthers

REFERENCES 8. Matsuzaki H, Yoshizu T, Maki Y, Tsubokawa N, Yamamoto Y, Toishi S: Long-

1. Dellon AL: Review of treatment results for ulnar nerve entrapment at the elbow. term clinical and neurological recovery in the hand after surgery for severe
J Hand Surg 14A:688-700, 1989. cubital tunnel syndrome. J Hand Surg 29A: 373-8, 2004.

2. Eaton RG, Crowe JF, Parkes JC III. Anterior transposition of the ulnar nerve with 9. Silver MA, Gelberman RH, Gellman H and Rhoades CE. Carpal Tunnel
a non-compressing fasciodermal sling. J Bone Joint Surg 62:820-825, 1980. Syndrome: Associated Abnormalities of Ulnar Nerve Function and the Effect of
Carpal Tunnel Release on These Abnormalities. J Hand Surg. l0-A, l985.
3. Gelberman RH, Eaton R and Urbaniak JR. Peripheral nerve compression. J Bone
Joint Surg. 75-A;12:1854-1878, 1993. 10. Tan V, Pope J, Daluiski A, Capo JT, Weiland AJ: The V-sling: A modified medial
intermuscular septal sling for anterior transposition of the ulnar nerve. J Hand
4. Gelberman RH, Editor: Operative Nerve Repair and Reconstruction. J.B. Surg 29A: 325-7, 2004.
Lippincott, Inc., Philadelphia, PA. July, 1991.
11. Townsend PF and Eaton RG: Long-term follow-up of stabilized anterior subcuta-
5. Gross MS and Gelberman RH. The Anatomy of the Distal Ulnar Tunnel. Clin neous transposition of the ulnar nerve. Read at the Annual Meeting of the
Orthop Rel Res. l96;238, l985. American Academy of Orthopaedic Surgeons, Washington, DC Feb 22, 1992.
6. Hicks D, Toby B: Ulnar nerve strains at the elbow: The effect of in situ decom- 12. Weirich SD, Gelberman RH, Best SA, Abrahamsson S-O, Furcolo DC and Lins
pression and medial epicondylectomy. J Hand Surg 27A:1026-31, 2002. RE. Rehabilitation following subcutaneous transposition of the ulnar nerve.
7. Kuschner S, Gelberman RH. Ulnar Nerve Compression at the Wrist. J Hand Immediate versus delayed mobilization. J Shoulder/Elbow Surg. 7:244-9, 1998.
Surg. 13-A;577, 1988.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
151
SYM 07:Layout 1 1/12/07 11:40 AM Page 152

RADIAL TUNNEL, POSTERIOR INTEROSSEOUS AND

WARTENBURG’S SYNDROME
Peter J. Stern, MD
SYMPOSIA HAND/WRIST

RADIAL NERVE COMPRESSION 4. Splints (not helpful in my experience)

Pertinent Anatomy: Radial Nerve Surgery: 3 primary approaches
• Arises from post. cord brachial plexus (C5-C8) 1. Anterolateral (Henry)
• Passes lat. and posterior in humeral spiral groove 2. Brachioradialis splitting (Lister)
• Pierces lat. I.M. septum 10-12 cm. proximal to lateral 3. Posterior approach (Thompson)
condyle
Results:
• ~ 5 cm distal and 5 cm proximal to elbow joint radial n. is
1. Lister,Blesole,Kleinert , J,H.S., 1979
anterior
• 19/20 w/ symptomatic relief at avg. 30 m.
• Divides into sensory branch (SBRN) & posterior
Ritts et al. COOR, 1987
interosseous (PIN) n. ~ 1cm. proximal to lateral condyle
• 51% good, 23% fair, 26% poor; Results less favorable than
• SBRN travels distally (deep to BR) and emerges 9 cm proxi-
previously reported
mal to radial styloid between BR and ECRL
Jebson et al. J. Hand Surg. 1997
• PIN, just distal to elbow joint, enters radial tunnel deep to
• 67% good or excellent; 33% fair or poor
arcade of Frohse (arch formed by superficial head of
supinator) POSTERIOR INTEROSSEOUS NERVE SYNDROME
• Motor supply:
Clinical Presentation
• BR and ECRL:Radial n.
• Wrist extends present (mildly weak) in radial deviation
• ECRB: variable
(ECU not firing)
• Emerges f. radial tunnel and supplies superficial and deep
• Can’t extend in neutral and ulnar deviation
externsors of wrist and hand
• Absent finger and thumb extension, absent thumb radial
RADIAL TUNNEL SYNDROME abduction
Take home points ➢ May be partial (incomplete)
• SBRN normal
• Pain syndrome: not a true entrapment neuropathy
• No sensory or motor findings on EDX Examination
• Palpate for proximal forearm mass
Presentation
• Loss of powerful wrist extension
• Pain over lateral elbow
• Loss of active extension at MCP joints
• Often radiates distally
• Absent on waking and progresses during day Evaluation
• Age: ~ 30-50 years 1. X-ray
2. EDX: denervation of muscles innervated by PIN
Sites of compression (FREAS)
3. MRI: soft tissue mass
1. Fibrous bands
2. Recurrent leash of Henry Causes
3. ECRB origin • Inflammatory: elbow synovitis; Mass; Trauma: Monteggia;
4. Arcade of Frohse (proximal edge supinator) Occupational: ???; Psychiatric: Hysteria; Systemic: pol-
> most frequent site of compression yarteris or lead poisoning; Parsonage Turner: (brachial
5. Supinator: distal edge rare plexitis)
Examination Treatment: usually surgical
• ABSENT motor and sensory deficits
WARTENBERG’S SYNDROME
• Pain on palpation over BR 2 cm distal to elbow crease
• AKA: cheiralgia paresthetica, radial sensory n. entrapment
(most important finding)
• Causes:
• Also + middle finger test & pain w/ resisted forearm supina-
tion ➢ entrapment SBRN between BR & ECR
➢ External causes: hand cuff or wristwatch
EDX: ➢ External fixateur
• Generally normal and not indicated • Symptoms and signs: shooting or burning pain over dorsal-
Differential Diagnosis radial wrist , thumb and index fingers; + Tinel; deceased
• Lateral epicondyltis Sensation 1st dorsal web space
• Cervical radiculopathy • DDX: de Quervain’s; LABC entrapment; C-6 radiculopathy
• Peripheral polyneuropathy • EDX: unreliable
• Non-surgical treatment: splint in wrist extension, activity
Non-surgical treatment modification; NSAID’s (??); steroid injection (????)
1. Rest • Surgery: only when all else fails
2. NSAIDs (???) + modalities
3. Avoid provocative activities

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
152 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 153

REFERENCES 8. Werner CO.Lateral elbow pain and posterior interosseous nerve entrapment. Acta
1. Lister GD, et al. radial tunnel syndrome. J Hand Surg [Am]. 1979;4:52.. Orthop Scand Suppl. 1979;174:1-62.

2. Roles NC, Maudsley RH. Radial tunnel syndrome: resistant tennis elbow as a 9. Hagert CG, Lundborg G, Hansen T.Entrapment of the posterior interosseous
nerve entrapment. JBJS. 1972;54 Br :499-508. nerve. Scand J Plast Reconstr Surg. 1977;11(3):205-12

3. Ritts GD, Wood MB, Linscheid RL Radial tunnel syndrome. A ten-year surgical 10. Dellon AL and Mackinnon SE. Radial sensory entrapment in the forearm. J Hand
experience. Clin Orthop. 1987 ;219:201-5. Surg. 1986:11A; 199-205.

4. Jebson PJ, Engber WD. Radial tunnel syndrome: long-term results of surgical REVIEW

SYMPOSIA HAND/WRIST
decompression. J Hand Surg . 1997;22-A:889-96. • Plate AM, Green SM Compressive radial neuropathies.AAOS Instr Course Lect.
5. Verhaar J, Spaans F.Radial tunnel syndrome. An investigation of compression 2000;49:295-304.
neuropathy as a possible cause. JBJS. 1991;73(A):539 • Gelberman RH. Operative Nerve repair and reconstruction. Lippincott, 1991,
6. Abrams RA, et al.Anatomy of the radial nerve motor branches in the forearm. J Chapters 72,73,74.
Hand Surg . 1997;22A:232-7. • Szabo, RM, 1989,Slack Publishers, pp. 176-199.
7. Yongwei P. et al. Nontraumatic paralysis of the radial nerve with multiple con-
strictions. Hand Surg . 2003;28-A:199-205.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
153
SYM 07:Layout 1 1/12/07 11:40 AM Page 154

RECURRENT CARPAL TUNNEL AND CUBITAL TUNNEL SYNDROMES

Ghazi Rayan, MD

CARPAL TUNNEL SYNDROME Surgical

• TCL release
SYMPOSIA HAND/WRIST

Patient Evaluation
• Excision of SOL
History
• Tenosynovectomy
• Initial symptoms: if completely relieved
• Neuroma management
• Present symptoms: similar or different
• Nerve grafting
• Difference in hand use
• Neurolysis (external - internal)
• Change in health status
• Tissue interposition
• Workers’ compensation claim
Adjunctive Procedures
Examination
Autogenous tissue interposition
• Scar assessment
- Non vascular
• R/O other nerve compressions
Dermal fat graft
• Patients behavior and psychological profile
Vein wrapping
Symptoms after carpal tunnel release - Vascular
• New Synovial
• Ephemeral Fascia
• Persistent Adipose
• Recurrent Muscle
New Muscle flaps
Iatrogenic Pronator Quadratus Muscle Flap
• Tendinous Abductor Digiti Minimi
• Vascular Palmaris Brevis
• Neurologic
CUBITAL TUNNEL SYNDROME
– Ulnar
– Median nerve Patient Evaluation
Palmar cutaneous branch* Symptoms
Recurrent motor • Paresthesias
Common digital • Pain
Communicating rami • Scar
Incisions linked to palmar cutaneous neuroma • Hypoesthesia
• Transverse • Dysesthesias
• Proximal to the wrist crease between PL & FCR tendons • Weakness
• Radially and distal to wrist crease at scaphoid tubercle Findings
Ephemeral • Sensory deficit
• Pillar pain 3 months • Muscle atrophy
• Weakness 6 months • Ulnar Nerve Instability
Persistent • Elbow Instability
• Continued symptoms • Provocative Tests
• 75 – 100% - Elbow flexion
• Incomplete release * - Tinel’s sign
• Double crush (cervical disc, pronator syndrome)
Potential Anatomic Areas of Ulnar Nerve Entrapment
• Double compression (cubital tunnel, TOS)
1) Arcade of Struthers
• Missed pathology (Space occupying lesion
2) Medial intermuscular septum
Recurrent
3) Arcuate (Osborne) ligament
• Pain free period
4) FCU aponeurosis
• < 25%
5) Common flexor aponeurosis
• Perineural scarring *
- prior trauma Factors Contributing to Recurrence
- traction neuritis • Failure to release all 5 anatomic structures
- traumatic handling of the nerve • Create a new area of entrapment
• Systemic illness diabetic neuropathy - Fascial band
• Reformation of flexor retinaculum? - Perineural fibrosis
Failure to do ancillary procedures
Treatment
• Neurolysis
Nonoperative
• Tenosynovectomy
Surgical
• Space occupying lesion
• External neurolysis alone
Treatment • Internal neurolysis alone
Nonoperative • Medial epicondylectomy
Local steroid injection • Thorough decompression
Therapy • Neuroma (ABC) management

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
154 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 155

• Subcutaneous transposition Potential Anatomic Areas of Radial Nerve Entrapment

• Submuscular transposition* • Fibrous bands anterior to radial head
• Adjunctive procedures • Radial recurrent vessels
Authors Preferred Method • Sharp tendinous margin of ECRB
• External neurolysis • Arcade of Frohse
• Internal neurolysis if necessary
Factors Contributing to Recurrence
• Release areas of compression

SYMPOSIA HAND/WRIST
• Perineural scarring
• Submuscular transposition
• Failure to release all anatomic structures
• Adjunct pedicle triceps muscle or fat flap
• Failure to release associated nerve entrapments
RADIAL TUNNEL SYNDROME
Treatment
Patient Evaluation Nonoperative
• Provocative maneuvers Surgical
• R/o other conditions • Neurolysis
– Lateral elbow tendinopathy • Thorough decompression
– Elbow Instability (combined tennis elbow and radial
tunnel releases)
– Other nerve entrapments such as musculocutaneous

REFERENCES 4. Dellon A L (1989). Review of treatment results for ulnar nerve entrapment at the
Carpal Tunnel elbow. Journal of Hand Surgery, 14A: 688-700.

1. Braun et al The retrograde radial fascial forearm flap JHS 20A 915-22;1995 5. Gabel G T and Amadio P C (1990). Reoperation for failed decompression of the
ulnar nerve in the region of the elbow. Journal of Bone and Joint Surgery, 72A:
2. Chang R Dellon. A Surgical management of recurrent carpal tunnel syndrome 213-219.
JHS B 467-70;1993
6. Godette G and Rayan G Medial triceps flap coverage for an ulnar neuroma
3. Cobb T Amadio P. Reoperation for carpal tunnel syndrome. Hand Cl 313- Orhopaedic Review 1993
23;1996
7. Green J R and Rayan G M (1999). The cubital tunnel: Anatomic, histologic, and
4. Curtis R Eversman.W. Internal neurolysis as an adjunct to the treatment of carpal biomechanical study. Journal of Shoulder and Elbow Surgery, 8: 466-470.
tunnel syndrome JBJS 55A733-40; 1973
8. Kleinman W B (1994). Revision ulnar neuroplasty. Hand Clinics, 10: 461-477.
5. Dellon A Mackinnon S. The pronator quadratus muscle flap JHS 9A 423-7;1984
9. Kleinman W B (1999). Cubital tunnel syndrome: Anterior transposition as a log-
6. Hunter J. Recurrent carpal tunnel syndrome, epineural fibrosis fixation and trac- ical approach to complete nerve decompression. Journal of Hand Surgery, 24A:
tion neuropathy. Hand Clin.491-04;1991 886-897
7. McClinton M. The use of dermal fat graft Hand Clin 357-64 1996 10. Pasque C B and Rayan G M (1995). Anterior submuscular transposition of the
8. Murray D, Saccone P, Rayan G. Complications following subfascial carpal tunnel ulnar nerve for cubital tunnel syndrome. Journal of Hand Surgery, 20B: 447-453.
release. Southerm Medical J 87:416-8;1994 11. Rayan G M (1992). Proximal ulnar nerve compression: Cubital tunnel syndrome.
9. O’Malley et al. Factors that determine reexploration treatment of carpal tunnel Hand Clinics, 8: 325-336.
syndrome JHS 17 A 638-41;1992 12. Rogers et al The failed ulnar nerve traasposition CORR 269:193-200;1991
10. Milward T et al. The abductor digiti minimi muscle flap. Hand 982-5;1977 13. Varitimidis S E, Riano F and Sotereanos D G (2000). Recalcitrant post-surgical
11. Rayan G. Understanding and managing carpal tunnel syndrome. The J of neuropathy of the ulnar nerve at the elbow: Treatment with autogenous saphe-
Muscculoskeletal Medicine 16:1999 nous vein wrapping. Journal of Reconstructive Microsurgery, 16: 273-277.
12. Reisman N Dellon A. The transposition of the abductor digiti minimi. Plast 14. Vogel B, Nossaman B, Rayan G. Revision anterior submuscular transposition of
Reconstr Surg 72:859-65; 1983 the ulnar nerve for failed subcutaneous transposition British J Plast Surg. 57:311-
16, 2004
13. Rose et al Palmaris brevis turnover flap as an adjunct to internal neurolysis of
the chronically scared median nerve in recurrent carpal tunnel syndrome J Hand 15. Gelberman R, Yamaguchi K, Hollstien S, et al. Changes in interstitial pressure
Surg 16 A 191-02; 1991 and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion
of the elbow. An experimental study in human cadavera. J Bone Joint Surg Am.
14. Strickland et al The hypothenar fat pad flap for management of recalcitrant 1998 ;80(4):492-501.
carpal tunnel syndrome JHS 21A 840-8;1996
Radial Tunnel
15. Wulle C The synovial flap as treatment of recurrent carpal tunnel syndrome
Hand Clin. 379-88;1996 1. Lister GD, Belsole RB,Kleinert HE. The radial tunnel syndrome J Hand Surg
[Am]. 1979 Jan;4(1):52-9.
16. Szabo RM, Gelberman RH. The pathophysiology of nerve entrapment syn-
dromes. J Hand Surg [Am]. 1987 Sep;12(5 Pt 2):880-4 2. Fuss FK, Wurzl GH. Radial nerve entrapment at the elbow: surgical anatomy J
Hand Surg [Am]. 1991 Jul;16(4):742-7
17. Gelberman RH, Pfeffer GB, Galbraith RT, Szabo RM, et al. Results of treatment of
severe carpal-tunnel syndrome without internal neurolysis of the median nerve. J 3. Riffaud L, et al Anatomic bases for the compression and neurolysis of the deep
Bone Joint Surg Am. 1987 Jul;69(6):896-903. branch of the radial nerve in the radial tunnel. Surg Radiol Anat.
1999;21(4):229-33
Cubital Tunnel
4. Sarhadi NS, Korday SN, Bainbridge LC. Radial tunnel syndrome: diagnosis and
1. Amadio, P C (1986). Anatomical basis for a technique of ulnar nerve transposi- management J Hand Surg [Br]. 1999 Feb;24(1):139-40
tion. Surgical-Radiologic Anatomy, 8: 155-161.
5. Sotereanos DG, et al Results of surgical treatment for radial tunnel syndrome J
2. Broudy A S, Leffert R D and Smith R J (1978). Technical problems with ulnar Hand Surg [Am]. 1999 May;24(3):566-70
nerve transposition at the elbow. Journal of Hand Surgery, 3A: 85-89.
6. Naam NH, Massoud HA. Painful entrapment of the lateral antebrachial cuta-
3. Caputo A E and Watson H K (2000). Subcutaneous anterior transposition of the neous nerve at the elbow J Hand Surg [Am]. 2004 Nov;29(6):1148-53
ulnar nerve for failed decompression of cubital tunnel syndrome. Journal of
Hand Surgery, 25A: 544-551.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
155
SYM 07:Layout 1 1/12/07 11:40 AM Page 156

COMPLICATIONS OF
SYMPOSIA HAND/WRIST

DISTAL RADIUS FRACTURES (Z)

Moderator: Peter H. Stern, MD, Cincinnati, OH (n)

This symposium follows a case-based format to discuss complications of distal radius

fractures and their management.

I. Introduction
Peter H. Stern, MD, Cincinnati, OH (n)

II. Complex Regional Pain Syndrome

Richard H. Gelberman, MD, Saint Louis, MO (n)

III. Ulnar-sided Wrist Pain

Hill Hastings, II, MD, Indianapolis, IN (c - Biomet)

IV. Malunion
Jesse B. Jupiter, MD, Weston, MA (a - AO Foundation, e - Wyeth Co, Amgen Co)

V. Complications of Plate Fixation

Peter H. Stern, MD, Cincinnati, OH (n)

VI. Case Discussion, Audience Questions and Answers

Peter H. Stern, MD, Cincinnati, OH (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
156 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 157

COMPLEX REGIONAL PAIN SYNDROME

Richard H. Gelberman, MD

I. Relationship of compression syndromes in the upper B. Time to diagnosis: 8 days – 10 weeks

extremity and reflex sympathetic dystrophy (Grundberg C. Time to decompression: 10-20 weeks

SYMPOSIA HAND/WRIST
and Reagan, JHS 1991) D. All improved with nerve decompression (71 30); visual
A. Terminology (e.g. algodystrophy, reflex sympathetic dys- analog pain score (7.5 1.8)
trophy, causalgia, etc.)— complex regional pain syn-
V. Key points
drome CRPS; (American Pain Society Meeting, 1993)
A. It is difficult to distinguish types I and II CRPS
1. A syndrome that develops after an initial noxious
B. This is primarily a clinical diagnosis (swelling, stiffness,
event (Type I) or with peripheral nerve compression
disproportionate pain, often with a positive Tinel’s sign)
(Type II)
C. Electrical studies are often negative in the early stages,
2. Spontaneous pain and/or allodynia/hyperalgesia not
positive several weeks later
limited to the territory of a single peripheral nerve and
D. Historically there has been hesitation to consider surgery
disproportionate to the inciting event
of any kind in the setting of CRPS
3. Evidence of edema, skin blood flow abnormality, or
E. Our experience indicates that operative decompression is
abnormal sudomotor activity
effective in relieving the pain and other somatic com-
4. Other conditions that would account for the degree of
plaints associated with Type II CRPS.
pain and dysfunction are excluded
F. Despite significant improvement in the DASH scores in
II. Relationship between nerve compression and CRPS (in our series, however, because of delays in treatment, many
order of frequency) patients had residual functional limitations (PIJ contrac-
A. Median nerve tures)
B. Ulnar nerve
VI. Summary
C. PIN/Superficial radial nerve (Monsivias, JHS-B, 1993)
Findings are subtle and are not classic for carpal tunnel syn-
III. Case example drome; requires high index of suspicion (pain, allodynia,
hyperalgesia, abnormal sudomotor activity) and prompt
IV.Nerve decompression for complex regional pain syn-
intervention.
drome Type II after upper extremity surgery (Goldfarb,
JHS 2005)
A. Report of 8 patients with pain out of proportion, marked
edema, dysesthesias, profound loss of finger motion

REFERENCES 10. Jupiter JB, Seiler JG, Zienowicz R. Sympathetic maintained pain (causalgia) asso-
1. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measure- ciated with a demonstrable peripheral-nerve lesion. Operative treatment. J Bone
ment of acute pain. Acad Emerg Med. 2001;8:1153–1157. Joint Surg. 1994;76A:1376–1384.

2. Casanova JS. American Society of Hand Therapists clinical assessment recom- 11. Legler J, Potosky AL, Gilliland FD, Eley JW, Stanford JL. Validation study of retro-
mendations. Chicago: American Society of Hand Therapists; 1992. spective recall of disease-targeted function (results from the prostate cancer out-
comes study). Med Care. 2000;38:847–857.
3. Dijkstra PU, Groothoff JW, ten Duis HJ, Geertzen JH. Incidence of complex
regional pain syndrome type I after fractures of the distal radius. Eur J Pain. 12. Lynch AC, Lipscomb PR. The carpal tunnel syndrome and Colles’ fractures.
2003;7:457–462. JAMA. 1963;185:363–366.

4. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H. Capturing the 13. McCarroll HR. Nerve injuries associated with wrist trauma. Orthop Clin North
patient’s view of change as a clinical outcome measure. JAMA. 1999;282:1157–116. Am. 1984;15:279–287.

5. Gelberman RH, North ER. Carpal tunnel release. In: Gelberman RH editors. 14. Monsivais JJ, Baker J, Monsivais D. The association of peripheral nerve compres-
Operative nerve repair and reconstruction. Philadelphia: Lippincott, Williams sion and reflex sympathetic dystrophy. J Hand Surg. 1993;18B:337–338.
and Wilkins; 1991;p. 899–912. 15. Parano E, Pavone V, Greco F, Majorana M, Trifiletti RR. Reflex sympathetic dystro-
6. Grundberg AB, Reagan DS. Compression syndromes in reflex sympathetic dystro- phy associated with deep peroneal nerve entrapment. Brain Dev. 1998;20:80–82.
phy. J Hand Surg. 1991;16A:731–736. 16. Placzek JD, Boyer MI, Gelberman RH, Sopp B, Goldfarb C. Nerve decompres-
7. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder, and sion for complex regional pain syndrome Type II following upper extremity sur-
hand (DASH) outcome questionnaire (longitudinal construct validity and meas- gery. J Hand Surg. 2005; 30A:69-74.
uring self-rated health change after surgery). BMC Musculoskelet Disord. 17. Reuben SS, Rosenthal EA, Steinberg RB. Surgery on the affected upper extremity
2003;14:1471–1474. of patients with a history of complex regional pain syndrome (a retrospective
8. Hord ED, Oaklander AL. Complex regional pain syndrome (a review of evi- study of 100 patients). J Hand Surg. 2000;25A:1147–1151.
dence-supported treatment options). Curr Pain Headache Rep. 2003;7:188–196. 18. Thimineur MA, Saberski L. Complex regional pain syndrome type I (RSD) or
9. Hove LM. Nerve entrapment and reflex sympathetic dystrophy after fractures of peripheral mononeuropathy? A discussion of three cases. Clin J Pain.
the distal radius. Scand J Plast Reconstr Surg Hand Surg. 1995;29:53–58. 1996;12:145–150. 13. Stein AH. The relation of median nerve compression to
Sudeck’s syndrome. Surg Gynecol Obstet. 1962;115:713–720.
19. Wong GY, Wilson PR. Classification of complex regional pain syndromes. New
concepts. Hand Clin. 1997;13:319–325.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
157
SYM 07:Layout 1 1/12/07 11:40 AM Page 158

ULNAR-SIDED WRIST PAIN

Hill Hastings II, MD

“There is a lot going on in a small space ulnarly!” ii. Decreased radial inclination and dorsal angulation
cause intermediate changes
SYMPOSIA HAND/WRIST

I. Anatomical Considerations
iii.Dorsal displacement: minimal changes
A. Distal radial metaphysis: Cancellous, thin cortex, espe-
B. Bronstein AJ, Trumble TE, Tencer AF J Hand Surg
cially dorsal radial
22(2):258-62, 1997 Mar
B. Articular surfaces
Dorsal tilt to 30° and radial translation to 10 mm led to
Radiocarpal 2-fossae: scaphoid and lunate
little restriction in Pro/sup
Normal relationships
i. 5 mm radial translation resulted in 23% loss of
i. Radial inclination – average 23°
pronation
ii. Radial length – average 13 mm. (8 – 18 mm.)
ii. Radial shortening of 10 mm reduced pronation by
iii.Volar tilt – average 11° (1 - 21°
47% and supination by 29%
C. Distal radioulnar joint (sigmoid notch) 60 – 80° con-
C. Ishikawa J, Ishikawa N, Miniami A J Hand Surg
cave surface
30A:1178-1184, 2005
i. Radius of curvature sigmoid notch almost twice that
i. Subluxation of DRUJ related to restricted forearm
of the distal ulna (15-19 mm. vs 10 mm)
rotation
ii. Ligamentous support essential for stability
ii. Dorsal tilt and ulnar positive variance adversely influ-
iii.Ulnar head slides dorsally in pronation and palmarly
ence dorsopalmar position of the ulnar head, restrict-
in supination
ing pronation and supination
D. Triangular Fibrocartilage Complex (TFCC)
D. Differential diagnosis: ulnar sided wrist pain
i. Ulnar collateral ligament
i. Ulnar impaction syndrome secondary to radius short-
ii. Articular disc
ening
iii.Dorsal and Volar distal radioulnar ligaments
ii. TFCC tear/synovitis
iv. Extensor carpi ulnaris and its sub-sheath
iii.LT tear/synovitis
v. Ulnocarpal ligaments
iv. Incongruity/arthritis DRUJ
a. Ulnotriquetral
v. Instability DRUJ
b. Ulnolunate
vi. Nonunion ulnar styloid
E. Lunotriquetral Joint
vii. Contracture DRUJ
viii. LT tear/instability
ix. Radial lesions
a. (i.e., scapholunate instability) with ulnar sided syn-
ovitis
b. Radiolunate arthritis
x. Ulnar tunnel syndrome
E. Treatment of specific lesions – Preserve the distal ulna!
Only excise as last resort!
a. Ulnar impaction
II. Associated lesions with distal radius fractures i. Restore variance to neutral
A. TFCC tears (Richards et al) ii. Ulnar shortening
i. 35% with IA fracture iii.Wafer (arthroscopic or open)
ii. 53% with EA fracture iv. Radius correctional osteotomy (lengthening)
B. SL ligament injury with instability (Richards et al) v. When severe radial lengthening & ulnar shortening
i. 21.5% of IA fractures b. TFCC tear/synovitis
ii. 6.7% of EA fractures i. Central: débride
C. RSL ligament: 90% (Hanker 1991) ii. Radial: débride or repair
D. Dorsal capsule: 66% (Hanker 1991) iii.Dorsal: repair
iv. Ulnar: repair (open)
III. Changes in joint reactive forces with fracture deformity c. LT tear
(Palmer AK) i. Dynamic (partial): débride, conservative
A. Normal ii. Complete: repair/graft
i. 80% radius iii.Static (VISI):
ii. 20% ulna a. Early, no degenerative changes: LT fusion and
B. 20° loss of normal volar tilt reconstruction, reconstruction ulnocarpal com-
i. 60% radius plex and radiotriquetral ligament
ii. 40% ulna b. Late (Fixed VISI and DJD)
C. Dorsal tilt shift axial load to dorsal aspect of scaphoid i. Proximal Row Carpectomy (PRC)
fossa and to dorsal ulnar wrist ii. Midcarpal fusion
IV.Effect of distal radius deformity on DRUJ function iii.Radiolunate and lunotriquetral fusion
A. Adams BD J Hand Surg 18(3):492-8, 1993 May iv. Total wrist fusion
i. Radial shortening greatest disturbance in kinematics When associated with TFFC central perfora-
and TFCC distortion tion, positive ulnar variance: also shorten
ulna
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
158 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 159

d. Incongruity/arthritis DRUJ f. Nonunion ulnar styloid

i. Extra-articular: radial osteotomy to reposition sig- i. Small/simple: excise
moid notch ii. Large (basilar): ORIF
ii. Intra-articular: resection arthroplasty g. Contracture DRUi. Deficient supination: palmar cap-
a. Matched resection sulectomy
b. Darrach excision i. Deficient pronation: dorsal capsulectomy
c. Sauve-Kapandji h. Radiocarpal arthritis: distal scaphoid excision, trique-

SYMPOSIA HAND/WRIST
d. Replacement distal ulna tral excision, radioscapholunate fusion
e. Instability DRUJ – Reattached ulnar TFCC (open) i. Ulnar tunnel syndrome: ulnar nerve decompression
i. ORIF ulnar styloid nonunion if at base
a. Beware: reattachment of styloid may not always
restore stability
ii. Ligament reconstruction

REFERENCES 12. Masaoka, Shunji. Longsworth, Serene H. Werner, Frederick W. Short, Walter H.
1. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Green, Jason K. Biomechanical analysis of two ulnar head prostheses. J Hand
Hand Surg 1993;18A:492-498. Surg. 27(5):845-53, 2002 Sep.

2. Berger, Richard A. Conney, WP. Use of an ulnar head endoprosthesis for treat- 13. May, Megan M. Lawton, Jeffrey N. Blazar, Philip E. Ulnar styloid fractures associ-
ment of an unstable distal ulnar resection: review of mechanics, indications, and ated with distal radius fractures: incidence and implications for distal radioulnar
surgical technique. Hand Clinics 21(4):603-*20, vii, 2005 Nov. joint instability. J Hand Surg 27(6):965-71, 2002 Nov.

3. Bronstein AJ, Trumble TE, Tencer AF. The effects of distal radius fracture 14. McKee, M D. Richards, R R. Dynamic radio=ulnar convergence after the Darrach
malalignment on forearm rotation: a cadaveric study. J Hand Surg 1997;22A:258. procedure. J Bone & Joint Surg 78(3):413-8, 1996.

4. Fernandez, D L. Capo, J T. Gonzalez, E. Corrective osteotomy for symptomatic 15. Peterson, M S. Adams, B D. Biomechanical evaluation of distal radioulnar recon-
increased ulnar tilt of the distal end of the radius. J Hand Surg 26:722-32, 2001 J struction. J Hand Surg 18(2):328-34, 1993 Mar.

5. Fernandez, D L. Jupiter, J B. Fractures of Distal Radius: A Practical Approach to 16. Sauerbier, M. Fujita, M. Neale, P G. Berger, R A. The dynamic radioulnar conver-
Management. Springer Second Edition 2002 gence of the Darrach procedure and the ulnar head hemiresection interposition
arthroplasty: a biomechanical study. J Hand Surg 27(4):307-16, 2002 Aug.
6. Gordon, K D. Dunning, C E. Johnson, J A. King, G J W. Kinematics of ulnar head
arthroplasty, J Hand Surg 28(6):551-8, 2003 Dec. 17. Sauerbier, M. Hahn, Michael E Fujita, Masaki. Neale, Patricia G. Berglund,
Lawrence J. Berger, Richard A. Analysis of dynamic distal radioulnar convergence
7. Haferkamp, H. Heidemann, B. Guhne, O. Deventer, B. Results of Kapandji-Sauve after ulnar head resection and endoprosthesis implantation, J Hand Surg.
procedure with distal radio-ulnar fusion and segmental resection of the ulna. 27(3):425-34, 2002 May.
Handchirurgie, Mikrochirurgie, Plastische Chirurgie. 35(3):170-4, 2003 May
18. Scheker, L. Babb, B. Killion, P. Distal Ulnar Prosthetic Replacement. Orthopedic
8. Hirahara, Hirotsune. Neale, Patricia G. Lin, Yu-Te. Cooney, William P. An, Kai- Clinics of North America. 30(2), 2001 Apr.
Nan. Kinematic and torque-related effects of dorsally angulated distal radius frac-
tures and the distal radial ulnar joint. J Hand Surg 28(4):614-21, 2003 Jul. 19. Short, WH, Palmer AK, Werner, FW, Murphy, DJ: A Biomechanical study of distal
radius fractures. J Hand Surg. 12:529-534, 1987
9. Ihikawa J, Iwasaki N, Minami A. Influence of distal radioulnar joint subluxation
on restricted forearm rotation after distal radius fracture. J Hand Surg 20. Sotereanos, D G. Leit, M E.A modified Darrach procedure for treatment of the
2005;30A:1178-1184. painful distal radioulnar joint. Clinical Orthopaedics & Related Research.
(325):140-7, 1996.
10. Kihara, H. Palmer, A K. Werner, F W. Short, W H. Fortino, M D. The effect of dor-
sally angulated distal radius fractures on distal radioulnar joint congruency and 21. van Schoonhoven, J. Kall, S. Schober, F. Prommersberger, K-J. Lanz, U. The
forearm rotation. J Hand Surg. 21(1):40-7. 1996 Jan. hemiresection-interposition arthroplasty as a salvage procedure for the arthroti-
cally destroyed distal radioulnar joint. Handchirurgie, Mikrochirurgie, Plastische
11. Lindau, T. Adlercreutz, C. Aspenberg, P. Peripheral tears of the triangular fibrocar- Chirurgie. 35(3):175-80, 2003.
tilage complex cause distal radioulnar joint instability after distal radial fractures.
J Hand Surg 25(3):464-8, 2000 May.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
159
SYM 07:Layout 1 1/12/07 11:40 AM Page 160

DECISION MAKING FOR DISAL RADIUS MALUNIONS

Jesse B. Jupiter, MD

I. Malunion of the Distal Radius 2. Comparative CT scan for rotational deformity

A. Do not treat x-ray but the patient who may be asympto- B. Types of Opening wedge Osteotomy
SYMPOSIA HAND/WRIST

matic. 1. “Rocking
B. Deformity can be extra-articular, intra-articular, or com- 2. Incomplete
bined. 3. Complete
C. Pathomechanics—Radiocarpal Joint C. Clinical Examples
1. Vector of deformity combination of angular and rota- D. Corrective Osteotomy—Volar Deformity
tional deformities. 1. Deformity = Increased volar tilt shortening pronation
2. – Displacement of flexion/extension arc deformity
– Dorsal Carpal Subluxation 2. Goals = Improve wrist extension and forearm supina-
– Articular Cartilage Overload tion restore DRUJ congruence improve appearance.
3. Short, et al. JHS 12A:529-34, 1987 E. Corrective Osteotomy—Intra-articular Malunion
With increasing dorsal tilt greater than 20º, 1. Problems - Joint Surface disruption articular incon-
increase force on distal ulna up to 67%. gruity carpal malalignment radiocarpal Subluxation
D. Pathomechanics—Midcarpal Carpal Joint 2. Considerations for Osteotomy
1. Adaptive DISI deformity Less than 6 months post injury
2. Park et al. J Hand Surg. 27A, 2002 Fracture pattern
Cadaver model with simulated malunion “Patients Extent of cartilage damage
with Adaptive DISI Patterns have higher chance of 3. Alternatives include:
symptoms than those with midcarpal alignment Radioscapholunate or radiolunate fuscon
maintained.” 4. Outcomes – Results very encouraging!
3. Midcarpal Instability
IV.Nonunion/Delayed Union
Type I DISI (LAX)—Reversed and corrected with
A. Possible Causes
osteotomy Type II DISI (Fixed)—Does not improve
1. Over distraction with Ext. Fix
after osteotomy—chronic intercarpal instability.
2. Failures to graft large defects
E. Pathomechanics of the Distal Radioulnar and Ulnocarpal
3. Extensive devascularization at surgery
Joints
4. Unstable construct with early motion
1. Instability
B. Problems
2. Incongruence
1. Small, osteopenic distal fragment
3. Impactation
2. Wrist and DRUJ capsular contracture
4. Contracture
3. Brachioradialis contracture
II. Corrective Osteotomy of Malunion— 4. Shortening (DRUJ Disruption)
General Considerations C. Alternative to ORIF – Arthrodesis
A. Goals Segalman and Clark. ASSH 1994
1. Reorientation of articular surface for normal load dis- 12 Patients
tribution. Required Multiple Surgeries to achieve fusion; wrist and
2. Reestablish mechanical balance of midcarpal joint. digital stiffness
3. Restore anatomic relationship of distal radioulnar 1. Tactics – Correct deformity soft tissue release if needed
joint. ORIF & bone graft additional procedure for DRUJ if
B. Indications: Functional limitations, pain, midcarpal needed
instability, DRUJ disruption, Articular incongruity 2. 10 Patients – 3 delayed union , 7 nonunions
C. Contraindications to Osteotomy (no healing after 4 mo), Avg F/U 3.6 years
1. Advanced arthrosis 100% union (10/10)
2. Fixed carpal instability 3 excellent
3. Decreased functional capacity 4 good
4. Profound osteoporosis 2 fair
5. Symptomatic CRPS 1 poor
D. Timing of Osteotomy 3 unsatisfactory results due to stiffness, carpal insta-
1. Early (nascent malunion) bility, or pair
2. Mature malunion E. Does Size of Distal Fragment Affect Resect?
3. Jupiter J, Ring D. JBJS 78A, 1996 Prommersberger et al. Chirurgie de la Main 21, 2002
Comparison of Early and Late Correction 13 pts with > 5 mm of subchondral bone
a) Ease of radial and DRUJ realignment 10 pts with < 5 mm of subchondral bone
b) Less soft tissue contracture No significant difference in outcome
c) No need for structural bone graft Union in 22/23 pts
d) Substantially less total disability
V. Conclusions
e) Early return to work
A. Malunion
III. Corrective Osteotomy—Tactics Most common complication of radius fx
A. Preoperative Planning—Extra—Articular Deformity-Dorsal IF symptomatic, osteotomy can improve function,
1. Based on radiographs of both wrists appearance, and carpal kinematics.
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
160 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 161

COMPLICATIONS OF PLATE FIXATION OF THE DISTAL RADIUS

Peter J. Stern, MD

Evolution in management • Plate removal infrequent

• 1960’s: CR + cast • Inconspicuous scar

SYMPOSIA HAND/WRIST
• 1970’s: pins & plaster • Minimal disturbance of anatomy
• 1980’s: Ex. Fix; +/- pins &/or bone graft — May be applied as a fixed angle construct (osteopenic
• 1990’s: ORIF dorsal approach +/- Graft bone)
• 2000+: ORIF volar approach ;Fixed angled devices; Bone Disadvantages
graft substitutes • Can’t visualize joint
• Bone grafting awkward
Internal Fixation: 2006
• Fixation failure
• Dorsal plates, fragment specific fixation, volar plates
Complications
Fragment specific fixation 1. Fixation failure
• Intra-articular comminuted fractures • Inadequate fixation
• Placement of plates or wire forms orthogonal (90°- 90°) to • Inadequate apposition
each other • Failure to graft
• Advantages: versatile, low profile • Patient factors
• Disadvantages: $$$, steep learning curve, sometimes exten- 2. Tendon irritation or rupture
sive dissection, tedious • Attrition from screws or edge of plate
• DORSAL: usually EPL or radial sided extensors
Dorsal Plates
• VOLAR: FPL
Indications:
3.Radial Artery Injury
Advantages:
• Iatrogenic
• Visualize articular surface
• Plate or screw irritation
• Bone grafting easier
4. Screw penetration into radiocarpal joint
• Avoid neurovascular structures
• Prevent by x-rays orthogonal to joint (Ref.#12)
Disadvantages
5. Failure to fix volar facet fragment (Ref.# 5)
• Tendon irritation
6. Stffness
• Tendon rupture
7. nerve injury
• High incidence of plate removal (12%-30%)
• Superficlal radial
Volar Plates • Palmar cutaneous branch Median nerve
Advantages: 8. Compartment Syndrome
• Provides stable subchondral construct • Rare
• Early ROM • Tissue damage + high energy trauma
• Plate irritation less

REFERENCES 7. Dao KD, Venn-Watson E. Shin AY. Radial artery pseudoaneurysm complication
1. Nazzal, A et al..A histologic analysis of the effects of stainless steel and titanium of using AO/ASIF volar distal radius plate. J Hand Surg. 2001:26A; 448.
implants adjacent to tendons: an experimental. rabbit study J Hand Surg. 8. Schnur DP & Chang B. Extensor tendon rupture after dorsal pi plate. Ann Plast
2006;31A:1123. Surg. 2000;29-789-91.
2. Bensen EC et al. Two Potential Causes of EPL Rupture after Distal Radius Volar 9. Khanduja V et al. Complications and functional outcome following fixation of
Plate Fixation.CORR.. 2006. complex, intra-articular fractures of the distal radius with the AO Pi-Plate. Acta
3. Rozental TD & Blazar P. Functional outcome and complications after volar plat- Orthop Belg. 2005;71:672-7.
ing for dorsally displaced, unstable fractures of the distal radius.J Hand Surg 10. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. JAAOS, 2005:13;
[Am]. 2006 Mar;31(3):359-65. 159-71.
4. Rozental TD,Berekjiklian PK Bozentka D. Funcitonal outcome and complications 11. Wong-Chung J. Quinlan W. Rupture of the EPL following fixation of a distal
following 2 types for unstable distal radius fractures. JBJS, 2004:85A, 1956 radius fracture. Injury. 1989: 20;375-76,
5. Harness NG, Jupiter JB, Orbay JL et al. Loss of fixation of the volar lunate facet 12. Boyer, MI et al. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of sur-
fragment in fractures of the distal part of the radius. JBJS, 2004; 86A; 1900-08. gical fixation.J Hand Surg . 2004 ;29-A:116-22.
6. Nunley JA & Rowan PR. Delayed rupture of FPL after inappropriate placement of 13. Gutow, AP. Avoidance and treatment of compilations of distal radius fractures.
pi plate on the volar surface of the distal radius. J Hand Surg. 1999; 24A: 1279-80. Hand Clin. 2005:21;295-305.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
161
SYM 07:Layout 1 1/12/07 11:40 AM Page 162

WHAT’S NEW IN PEDIATRIC ORTHOPAEDICS:

S Y M P O S I A P E D I AT R I C S

MANAGEMENT OF SPORTS INJURIES IN THE

ADOLESCENT ATHLETE (V)
Moderator: Mininder S. Kocher, MD, Boston, MA (n)

This symposium overviews the current controversies and management of sports injuries in
the adolescent athlete by pediatric sports medicine experts.

I. Pediatric and Adolescent Athletes are Not Little Adult Athletes: Pediatric Sports
Medicine
Carl Stanitski, MD, Kiawah Island, SC (n)

II. Upper Extremity Injuries in the Adolescent Athlete

Peter Waters, MD, Boston, MA (n)

III. ACL Injury in Skeletally Immature Patients: A Management Algorithm based on

Physiological Age
Mininder Kocher, MD, Boston, MA (n)

IV. Cases/Questions
Panel

V. Juvenile Osteochondritis Dissecans of the Knee: Current Concepts in Evaluation

and Management
Theodore Ganley, MD, Bryn Mawr, PA (n)

VI. Patellofemoral Disorders in the Adolescent Athlete: A Rational Approach to the

Evaluation and Management of Patellofemoral Pain and Instability
Carl Stanitski, MD, Kiawah Island, SC (n)

VII. Foot and Ankle Injuries in the Adolescent Athlete

Michael Busch, MD, Atlanta, GA (n)

VIII. Case Presentations

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
162 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 163

PEDIATRIC AND ADOLESCENT ATHLETES—

ARE NOT JUST SMALL ADULT ATHLETES
Carl L. Stanitski, MD

S Y M P O S I A P E D I AT R I C S
Peds and Adolescent Sports – > 12 yo girls; 14 yo boys
• Scholastic Ages = Largest Number of Participants
COORDINATION
• Adult Celebrity Athlete Role Model
• MULTIPLE TYPES
– Performance expectations
– Hand-eye
– Training methods
– Hand-hand
– Injury treatment/recovery expectations
– Hand-foot
– All are future professionals and/or Olympians, World
– Foot-foot
Champs
– Foot-eye
– Parental, Peer, Coach pressures
• Early emphasis on one type leads to feeling of athletic fail-
• 3 “Bs”; “Best athlete on the team”; “Knows how to play with
ure at 10 yo and chronic “right fielder for life”
pain”
– Find the correct sport to fit the ability, e.g, soccer, swim-
Peds and Adolescent Sports ming, wrestling, running, gymnastics, etc.
• Significant rise in over-all # of hs athletic participants
Peds and Adolescent Sports
• 1971-1972 school year ~ 4 million participants
• Injury Risk Factors-Extrinsic
• 2005-2006 school year ~ 7.2 million participants
• Sport Specific
• Title IX impact !!!
– Non-Contact
• Increased # of sport offerings (30)
– Contact: Rare, Occasional. Common
Peds and Adolescent Sports – Collision
• Increased Earlier Emphasis in Competition; Single Sport – Technique demands
Focus • Overuse
• Earlier Participation – Training error: Too much, Too soon; Too Much
• Increased Number of Scholastic and Community Teams – Game overuse; “Throwers”
• Title IX • Equipment
– Size; Field size; Ball size
Peds and Adolescent Sports
• “Premature Professionals” Peds and Adolescent Sports
– Camps; Travel Teams • Injury Risk Factors-Intrinsic
– HS sports on national TV • Personal
– HS Section in JSI, USAToday • Sports Mechanics
– Loss of focus, purpose – More enthusiasm than skill
• Rise of Alternative Sports • Maturity: Strength, endurance, flexibility, co-ordination
• ??? Rise of All These Sports, Why the OBESITY Epidemic??? • Physeal Injury: Ligament 3x stronger
– Very limited % of participants – No “stress” radiographs for suspected SH I distal femoral
or proximal tibial physeal fractures
DIFFERENCES
• Added trauma; does not change treatment
• Often lack of appreciation by coaches of differences and
ongoing variability of sports readiness, skills, co-ordination, INJURY DATA
strength, endurance, flexibility and fitness level among par- • CDC funded pilot study-hs sports injuries Nine sports
ticipants • Compared with previous decade data
• Until 8-9 yo, girls = boys in speed, strength, endurance • 100 schools; ATC driven
• Changes in cardio-pulmonary, neurologic and muscu- • ~ 50% in injuries over 10 years ??? Rule changes, equip-
loskeletal systems ment, improved diagnostic ability
• Football highest/1000 exposures; softball, basketball lowest;
DIFFERENCES
80% = new injury
• Variables of Growth, Development
• Estimated 4.1 million hs athletes with projected 1.4 million
– Onset, rate, duration, magnitude
injuries, 2.4/1000 xp
– Physiological “No-Man’s Land” of Adolescence
• ~500K MD visits; 30K hospitalizations
• F=MxA
• Some major? of methodology-injury definition
• 100 Pounds of Peach Fuzz and Baby Fat vs 100 pounds of
Mustache and Muscle Peds & Adolesc Sports
• Male, Female Differences • Most injuries are minor and self-limiting
– “Overuse”
DIFFERENCES
– Youth: 15%; 5% “Serious”
• SADD = “Sports Attention Deficit Disorder”
– HS: 30%-40%; 15% “Serious”
• “Atheloids”
– Contact vs Collision
• Types of Co-ordination
– ??? Change with single sport emphasis/injury exposure
– Xs emphasis on hand-eye
time
– Throw, catch, hit a ball
• Sports, like life, have risk: benefit ratios
• Drop-off in Participation

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
163
SYM 07:Layout 1 1/12/07 11:40 AM Page 164

ADVANCES • NOT a screening test-abused

• Nutrition; Hydration • “New Test” = H and P
• Training Methods • Arthroscopic Surgery
– Exercise physiology: “Core”; Open/Closed Chain
ADVANCES
Exercises; Plyometrics; Biomechanics
Recognition that children do get major knee injuries
– Resistance Training
Hemarthrosis is a sign of a major knee injury
• Neuro-adaptation; more complete and synchronous muscle
S Y M P O S I A P E D I AT R I C S

contractions in pre-pubescent Negatives/Challenges

• Decrease injury, improve performance • Xs number of leagues, teams
• Strength training, not weight lifting • Adult dominance of organization of “Fun”
• Increased Size, Strength, Speed, Leaping, Endurance • Peer, Parental and Coach Pressures
• Inappropriate Goals, Demands and Expectations of
ADVANCES
Performance
• Equipment
• Performance Enhancing Drugs
– Size appropriate
• Accelerated Rehab Peds and Adolescent Sports
– From fracture experience • Unique group physiology
• Joint motion • Broad spectrum of multiple anatomic, growth, developmen-
• Prevent disuse, misuse tal, training and injury factors
• Rule Changes • Do not expect nor demand adult equivalent performances
– Fairness; Safety • Children are children---not adults
ADVANCES
• Imaging
– CT Scans
– Sonography
– Isotopic Scans
– MRI: Static, Dynamic

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
164 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 165

SHOULDER, ELBOW, WRIST INJURIES WITH PEDIATRIC AND

ADOLESCENT SPORTS PARTICIPATION
Peter M. Waters, MD

S Y M P O S I A P E D I AT R I C S
Sites of Injury • Positive clinical signs of impingement and rotator cuff ten-
All sports, all injuries donitis
Ankle 23% • Non-surgical treatment aimed at shoulder stabilization
Knee 17% • Do not rehabilitate like adult rotator cuff tears
Hand, Wrist, Elbow 13%
Multi-Directional Instability
Shoulder 6%
• Generalized laxity
SHOULDER PROBLEMS • MDI by shoulder exam
• Rehabilitate with strengthening, time
Static Stability
— Role of:
• Capsule
• capsular shift:open, arthroscopic
• Superior, middle, inferior glenohumeral ligaments
• thermal capsulloraphy
• Labrum
Shoulder Arthroscopy
Dynamic Stability
• Muscle synergy critical Role of Thermal Probes
• Shear forces of deltoid, latissimus, and pectorals must be • MDI?
counterbalanced by rotator cuff to prevent excessive transla- • Failed rehab?
tion and impingement • No role?
• POSNA presentation AAOS speciality day
Anatomic Issues
• Physis Shoulder Arthroscopy
• Ligamentous laxity • Role of arthroscopic stabilization: acute? recurrent?
• Muscle imbalance • Indications not yet defined in adolescents
• Growth acceleration • Many manufacturing materials, techniques
Clinical Issues Little Leaguer’s Shoulder
• Recurrent instability • Physeal stress injuries to proximal humerus
• Physeal Stress • Clinical tenderness at physis
• Overuse • Restricted motion
• Xrays may have physeal widening
Clinical Care Options
• Rare condition
1. Rehabilitation
• Responds to rest
2. Surgical: open, arthroscopic
3. Coaching, counseling ELBOW PROBLEMS
Recurrent Anterior Instability Valgus Overload Continuum
• Multi-directional instability associated with ligamentous
Skeletal Development
laxity = Rehabilitation
• Capitellum
• Post-traumatic labral and capsular tears = Surgical
— -18 months
Intervention
• Radial Head
Shoulder Subluxation — -2 years
• “Dead Arm Syndrome” • Medial Epicondyle
• Generalized laxity, growth spurt — -5 years
• Increased anterior translation with abduction, external rota- • Trochlea
tion, extension — -8 years
• Olecranon
Throwing Mechanics
— -10 years
• Windup
• Lateral Epicondyle
• Early cocking: abduction and external rotation
— -12 years
• Late cocking: maximum external rotation
• Acceleration: internal rotation Contralateral Views
• Deceleration
Throwing Phases
• Follow-through
The Apophysis is Vulnerable!
Shoulder Subluxation
• Rehabilitation with progressive resistive strengthening pro- Cartilage is Vulnerable!
gram, scapular stabilization
Little League Elbow
• Posterior capsular stretching
• Brogden BG, Crow NE
• Technique evaluation and coaching
— AJR 83: 671-675, 1960
Impingement Syndrome • Houston, Eugene, Oklahoma Surveys
• Laxity and MDI in adolescents — 20-58% elbow pain
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
165
SYM 07:Layout 1 1/12/07 11:40 AM Page 166

• Little League, Inc. — olecranon fossa

— 1972 rules • Posterior tension:
• Burden of Disease — triceps strain
— >2 million US participants • Anterior traction:
— Permanent sequelae — coronoid, brachialis
Radiographic Assessment Osteochondritis Dessicans
• Radiographs • Avascular necrosis capitellum and/or radial head
S Y M P O S I A P E D I AT R I C S

— include obliques • Classic phases of AVN

— contralateral elbow • Treatment depends on phase and severity
• MRI
Osteochondritis Dessicans
• Arthrography, CT
• Flexion contracture
Little League Elbow • Osteochondral softening
• Relates to number of hard throws per week, types of pitches • Fragmentation
thrown • Loose bodies
• Innings pitched vs “hard throws” per time • Capitellar - radial head deformity, incongruity
• Responds to rest, growth • DJD
• Prevention is key
Osteochondritis Dessicans Treatment
Elbow Throwing Injuries • Rest
• LITTLE LEAGUE ELBOW • Protect
— Medial tension • Restore full extension
— Lateral compression • Maximize osteochondral healing
— Anterior and posterior articular injuries • ?immobilize, motion
— Lateral tension • ?drilling, bone graft, anchors, cartilage transplant?
• Role of chondral drilling: used
Little League Elbow
• ORIF for repairable osteochondral lesions absorbable
• Medial tension:
anchors, buried hardware
— Medial epicondyle avulsion
• Cartilage transplant under consideration
— Pronator-flexor origin strain
— Medial collateral ligament strain Indications: Arthroscopy
— Ulnar nerve subluxation • Surgical debridement synovitis, osteochondral lesions
• Arthroscopy (anterior) vs open procedure: arthroscopy
Medial Epicondyle
dominates (AJSM)
Medial Epicondyle Fractures
Elbow Arthroscopy
• CLASSIFICATION
• Risk of neurovascular compromise
— Non-displaced
• Skill dependent
— Displaced (>5mm)
• Debridement, removal of loose bodies, synovitis
— Entrapped
• Anterior pathology
— Stress
Elbow Arthroscopy
Operative Indications
• Diagnois
• Displacement >5mm
• Debridement
• Ulnar neuropathy
• Excision loose bodies
• Entrapment
• OCD drilling, repair
• Gravity stress test for valgus instability
• Capsular release
Medial Epicondylar Stress FX • Anterior pathology
• Widened apophysis
Ulnar Neuritis
• Avulsion fracture
• Subluxation or dislocation ulnar nerve common in children
• Local tenderness only
and adolescents
• Treat with rest until healing
• Positive Tinel’s sign and elbow flexion test
• Rehabilitation: strengthening, technique coaching
Ulnar Neuritis
Medial Collateral Ligament
• Protect, rest, lessen trauma
• Common site of injury in adult pitchers
• Subluxating nerve = long-term risk for neuropathy
• May be strained in high school age pitchers
• Subcutaneous or submuscular transposition if symptoms
• Stress exam often reproduces pain
persist and continuation of activity desired
Medial Collateral Ligament
Little League Elbow Prevention
• MRI may reveal injury
• Little League, Inc
• Rare need for surgery
— Innings per Week
• Rehabilitation, pitching coaching
• 9-12 years old:
Lateral, Anterior, Posterior • <6 innings per week
• Lateral compression: • 13-15 years old:
— radio-capitellar • <9 innings per week
— osteochondral injury, AVN, OCD — Rest Days
• Posterior compression • <3 Innings: 1 day rest

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
166 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 167

• >4 Innings: 3 days rest Ligament Tears

• Rare injury but greater than case reports
Prevention
• Associated osteochondral lesions
• Early Recognition
• Impingement
— Rest
• Dynamic instability
— NOT
• Both
• Play through pain
• Throw itself out Pediatric Scapholunate

S Y M P O S I A P E D I AT R I C S
— Medical Care
Ligament Tears
— PREVENT PERMANENT CHONDRAL INJURY
• Partial tears more common
— Education
• Arthroscopic debridement alone may relieve pain, restore
• Coaches, Parents, Officials
function
— The problem with youth sports can be the adults.
• Long-term unknown (5/34 arthroscopic failures)
WRIST PATHOLOGY IN THE ADOLESCENT • Complete tears less common
Times are changing…... • Ligament reconstruction
• Blatt dorsal capsulodesis
Adolescent Wrist Pain
• Most injuries are related to accelerated growth, overuse syn- Midcarpal Instability
dromes
Recurrent Subluxation
• Occur at time of relative weakness and increased demands
• Incidence appears to be increasing
for performance
• Competitive female athletes
Adolescent Wrist Pain • Hyperelasticity
• Associated with generalized ligamentous laxity • Debridement alone short term solution
• Mid-carpal instability by exam • Long term: capsular tightening?
• Xrays usually normal
TFCC
• MRI, arthrograms usually normal
• Stabilizes distal radial ulnar joint
Adolescent Wrist Pain • Ulnocarpal ligaments
• Alteration in activities, strengthening program (puddy not • Central (1A), peripheral (1B), volar, (1C), radial (1D) tears
weights) for 6-12 weeks
TFCC Tears
• Majority (~80%) respond and return to full activities
JHS 1998
• Failures need further evaluation
• Associated with previous injuries: radius fractures, radial
Wrist Sports Injuries growth arrest, ulnar styloid non-unions, DRUJ instability
• Adolescent sports-related wrist pain: midcarpal instability, • Treat all associated problems with TFCC treatment
recurrent subluxations, scapholunate tears, TFCC tears • Majority of adolescent lesions 1B, then 1D
• Fractures: distal radius, ulna, and scaphoid • Ulnocarpal impaction syndromes
• Ulnar styloid non-unions, hypertrophic unions
Adolescent Wrist Pain
• Scapholunate ligament partial tears TFCC Treatment
• Dynamic instability patterns • Ulnar shortening
• Chondral injuries • Repair TFCC
• TFCC tears • Stabilize DRUJ
• Radial osteotomy
Evaluation of the failures...
• Psychological profiling TFCC Tears
• Imaging Peripheral tears (Palmer 1B) most common
• Radiographs • Radial insertion tears (Palmer 1D) most difficult to treat
• Arthrograms
TFCC REPAIR
• MRI
• 1B lesions repair with outside-in or inside-out suture
• Arthroscopy
• 1D lesions may require trans-radial repair
Pediatric Scapholunate Injuries
Wrist Arthroscopy
• Normative values exist for age and gender for S-L distance
INDICATIONS:
by xray
• Debridement osteochondral lesions, synovitis, partial liga-
• MRI may be diagnostic although often difficult to interpret
ment tears
(15/34 true positives)
• Repair, debride TFCC tears
MR Imaging • Assist percutaneous fixation intra-articular fractures with
direct visualization
Pediatric Scapholunate

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
167
SYM 07:Layout 1 1/12/07 11:40 AM Page 168

ACL RECONSTRUCTION IN THE

SKELETALLY IMMATURE ATHLETE
Mininder S. Kocher, MD
S Y M P O S I A P E D I AT R I C S

Youth Sports Diagnostic Performance of Clinical Examination & Selective MRI

• Less Free Play in the Evaluation of Knee Injuries in Children and Adolescents
• Greater Intensity Kocher MS et al (American Journal of Sports Medicine, 2001)
• Higher Competitive Levels
Associated Injuries
• Single Sport Focus
• Kocher et al (2004 AAOS)
• Parents, Coaches, Scouts
— 99 consecutive ACL tears
• $
– skeletally immature pts (14.2 yrs old)
Benefits of Youth Exercise — Chondral Injuries
• Medical – 6% (6/102)
— Obesity — Meniscal Injuries
— Diabetes – 49% (49/102)
— Cardiovascular risk » medial (16), lateral (26), both (4)
— Bone Health » bucket-handle (10), longitudinal (17), radial (7)
• Psychosocial complex (8)
— Self-esteem
Age
— Teen Pregnancy
• Chronological Age
— Recreational Drug Use
• Skeletal Age
— Career Success
— Greulich & Pyle
Change in Approach – Hand & Wrist
• Tibial Spine Fx — Pyle & Hoerr
— “Pediatric ACL Injury” – Knee
• Cast & Heal • Physiological Age
— Nonoperative Treatment — Tanner & Whitehouse
– Stage 1: Prepubertal
Agenda
– Stage 2: Prepubertal
• Knee Evaluation
– Stage 3: Pubertal: Young Adolescent
• Tibial Spine Fracture
– Stage 4: Pubertal: Older Adolescent
• ACL Epidemiology
– Stage 5: Skeletally Mature
• ACL Nonoperative Treatment
• Partial ACL Tears Tibial Eminence Fracture
• ACL Reconstruction • “Pediatric ACL injury”
• Growth Disturbance • Anatomy
• Recommendations 2006 — ACL attaches to intercondylar eminence
• Conclusions • Mechanism of Injury
• History — sports
— Kids don’t talk/ Parents talk alot — bicycle
• Physical Examination • Etiology
— Cooperation & Relaxation — relative strength: eminence vs ACL
— Distraction — loading conditions
• Knee – Noyes (JBJS 1974)
— Laxity & Contralateral Knee
ACL Injury versus Tibial Spine Fx in the Skeletally Immature
• Non-Knee
Knee: A Comparison of Skeletal Maturity and Notch Width
— Laxity, Alignment, Imbalance
Index
• Imaging
Kocher et al (Journal of Pediatric Orthopaedics, 2004)
— Radiographs
• Retrospective Case-Control Study
— MRI
— 25 midsubstance ACL
• Associated injuries
— 25 tibial spine fx
MRI – age matched (11.8 yrs old); sex matched
• Cartilage • Comparison
— physis, epiphysis, articular cartilage, meniscus — skeletal maturity
• Patient/ parent demands — notch width index (NWI)
• Meniscus signal changes in asymptomatic children • Findings
— Kaplan et al (AJR 1991) — skeletal maturity
— Takeda et al (JBJS-B 1998) – -0.5 vs –0.3, P=0.617
— notch width index
– 0.230 vs 0.253, P=0.020

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
168 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 169

• Signs & Symptoms • Janarv et al (JPO 1995)

– hemarthrosis — laxity 3-9 mm in 38% (functionally not significant)
– lack extension (bony block) • Willis et al (JPO 1993)
– anterior laxity — anterior laxity in 64% (50 pts) @ 4 yrs
• Imaging — no complaints of instability
– lateral knee x-ray • Kocher et al (Arthroscopy-2003)
• Classification — Laxity: 6.1 mm KT-1000 MMD

S Y M P O S I A P E D I AT R I C S
– Meyers & McKeever (JBJS 1959) — Function: 99.5 Lysholm Score
• Type I minimal displacement • Recommendations 2006:
• Type II hinged — Type I Fractures:
• Type III completely displaced — long-leg cast: extension
— Type II & III Fractures:
– Treatment Options — Aspiration & Reduction
• Nonoperative — Nonreducible: ARIF
– Cast Immobilization — Fixation Options
– Closed Reduction & Cast — Cannulated 3.5 mm Epiphyseal Screws
• Operative — Suture
– Open Reduction & Internal Fixation
ACL Injury
– Arthroscopic Reduction & Internal Fixation
• Increased Frequency
» Suture, Screws, Wires
— prevalence, incidence: ?
Displaced Tibial Spine Fracture — increased participation, competitive level, younger age
– Operative Treatment Recommended — increased awareness, arthroscopy, MRI
• Anatomic Reduction • Acute Traumatic Hemarthrosis:
– Lack of Extension — Vahasarja (1993): 138 pts. 23%
– Instability — Stanitski et al (1993): 65 pts. 47%
• Early Mobilization — Kloeppel-Wirth (1992): 35 pts. 26%
• Associated Injuries — Eiskjaer et al (1988): 40 pts. 45%
– Chondral Injury • Female ACL Injury
– Meniscal Injury — NCAA Surveillance Studies
• Entrapped Meniscus – 2x – 8x increased risk
– basketball, soccer
Entrapped Meniscus
— Pediatric & Adolescent
– Case Reports
– Shea et al (POSNA 2005)
• Falstie-Jensen (Injury 1984)
• Burstein (Arthroscopy 1988) Controversy
– Knee Pain • Initial Management
• Chandler (Arthroscopy 1995) — Nonoperative vs Operative
– Common • Operative Management
• Mah (J Pediatr Orthop 1998) 8/10 type 3 fx — Technique
– Not Common – Nontransphyseal
• Lowe (J Bone Joint Surg 2002) 0/12 type 3 fx – Partial Transphyseal
– Transphyseal
Tibial Eminence Fractures in Children: Prevalence of Meniscal
— Graft Choice / Fixation
Entrapment
— Age / Skeletal Maturity
Kocher et al (American Journal of Sports Medicine, 2003)
• Complications
• Retrospective Case Series
— Growth Disturbance
— 80 skeletally immature pts
– 1993-2001 (n=136) Nonoperative Rx (complete tears):
– nonreducible tibial spine fx (n=80) • Angel & Hall (Arthroscopy 1989)
– 23 Type II, 57 Type III — 5/7 failure (ACL reconstruction)
– operative treatment – Graf et al (Arthroscopy 1992)
• Findings — 7/8 failure (ACL reconstruction, meniscal tears)
— meniscal entrapment – Janarv et al (J Pediatr Orthop 1996)
– Type II fx: 26% (6/23) — 16/23 failure (ACL reconstruction)
– Type III fx: 65% (37/57) – Mizuta et al (JBJS-B 1985)
— entrapment — 1/18 return to preinjury sport level, 6/18 meniscal tears
– anterior horn medial meniscus (36) – McCarroll et al (AJSM 1988)
– intermeniscal ligament (6) — 3/16 return to preinjury sport, 4/16 meniscal tears
– anterior horn lateral meniscus (1) – Millett et al (Arthroscopy 2002)
Prognosis — ⇑ medial meniscus tears with delay in treatment
• Gronkvist et al (JPO 1984)/ McLennan (JPO 1995) Partial Tears of the ACL in Children and Adolescents
— recommended ORIF for displaced fractures Kocher MS et al (American Journal of Sports Medicine, 2002)
— more laxity in closed treatment vs fixation • Prospective Cohort Study
• Baxter & Wiley (JBJS 1988) — Skeletally Immature
— mild-moderate knee laxity in 45% pts – 45 pts, 13.9 yrs old, 6.1 yr F/U
— functionally not significant
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
169
SYM 07:Layout 1 1/12/07 11:40 AM Page 170

— Arthroscopically Documented Partial Tear Growth Disturbance

— Exclusion Criteria • Animal Models
– ACL Reconstruction — Guzzanti (JBJS 1994)
» Repairable Meniscal Tear – Rabbit, 2mm tunnels, 3/21 Disturbance
» IKDC C or D Lachman/ Pivot Shift Exam — Stadelmeier (AJSM 1995)
— Treatment: No ACLr, PT & Bracing – Canine, 5/32” tunnels, No Disturbance
— Outcome — Edwards (JBJS 2001)
S Y M P O S I A P E D I AT R I C S

– 31% (14/45) Subsequent Reconstruction – Canine, 80N, Femoral Valgus

• Clinical Series
Extra-Articular Reconstruction
— 2 Cases
• McCarroll et al (AJSM 1988)
– Lipscomb (JBJS 1986)
— 10 pts (skel immature); IT band tenodesis; 26 mo F/U:
– Koman (JBJS 1999)
10/10 laxity, 5/10 instability
Management and Complications of Anterior Cruciate Ligament
Repair
Injuries in Skeletally Immature Patients: A survey of The
• Engebetsen et al (Acta Orthop Scand 1988)
Herodicus Society and The ACL Study Group
— 8 pts (skeletally immature); repair to femur; 3-8 yrs F/U:
Kocher et al (Journal of Pediatric Orthopaedics, 2002)
8/8 laxity, 5/8 instability
• 8 Cases: Distal Femoral Valgus with Bony Bar
Physeal-Sparing ACLr — 3: Implants (Interference Screws) across Physis
• Brief (Arthroscopy 1991) — 3: Patellar Tendon graft bone block across Physis
— 6 pts (skeletally immature); hamstrings; 3-6yr F/U: 6/6 — 1: Large (12 mm) Tunnel with Patellar Tendon graft
laxity, 1/6 instability — 1: Over-the-Top Graft Placement
• Guzzanti et al (AJSM 2003) • 2 Cases: Genu Valgum without Bony Bar
— 8 pts (prepubescent); hamstrings, tibial tunnel; 2-7yr — Lateral Extra-Articular Tenodesis
F/U: 1.8mm laxity, 0/8 instability • 2 Cases: Leg-Length Discrepancy
• Anderson et al (JBJS 2003) — 2.5cm shortening (PT bone block across physis)
— 12 pts (skeletally immature); hamstrings & tunnels; 2-8yr — 3.0cm overgrowth (6mm hamstrings graft)
F/U: 1.5 laxity, 0/12 instability • 3 Cases: Recurvatum with Apophyseal Bar
• Kocher et al (JBJS 2005) — Hardware across Tibial Tubercle Apophysis
— 44 pts (prepubescent); ITB extra & intra-articular; 2-15 yr
Recommendations
F/U: 4.5% revision, 96 & 97
• Avoid Hardware across Lateral Distal Femoral Physis
Partial Transphyseal ACLr • Avoid Hardware across Tibial Tubercle Apophysis
• Andrews et al (AJSM 1994) • Avoid Bone Plugs across Physes
— 8 pts (open physes); soft tissue allografts; tibial physis- — Hamstrings Graft
>over the top • Avoid Large Tunnels
— 58 month F/U: 3/8 >3mm laxity, 1/8 poor result, no LLD • Avoid Extra-Articular Tenodesis
• Lo et al (Arthroscopy 1997) • Consider Physeal Sparing Reconstruction in Prepubescent
— 5 pts (wide open physes); soft tissue autografts; tibial Patients
physis->over the top — Minimal Over-the-Top Dissection & Notchplasty
— 7.4 yr F/U: 0/5 >3mm laxity, 1/5 poor result, no LLD
ACL Reconstruction in Skeletally Immature Knees: An
Transphyseal ACLr Anatomical Study
• Lipscomb & Anderson (JBJS-A 1986) Kocher MS et al (American Journal of Orthopaedics, 2005)
— 24 pts (12-15 yrs old, 11 wide open physes); hamstrings • Avoid Over-the-Top Dissection
autografts • Avoid Vigorous Notchplasty
— 35 month F/U: 15/24 return to sport, 1.6 mm laxity, 1.3 — Pediatric cadaveric ACL reconstruction
cm LLD, 2.0 cm LLD — OTT – Perichondrial Ring
• Matava & Siegel (Am J Knee Surg 1997) – 5.1 mm
— 8 pts (skel immature, 14.9 yrs old); hamstrings autografts — Paletta (Am J Sports Med 2001)
— 32 month F/U: 8/8 return to sport, 3/8 >3mm laxity, no – 2.9 mm
LLD • Adolescents with Growth Remaining (T3)
• McCarroll et al (AJSM 1994) — Quadrupled Hamstrings
— 47 pts (skeletally immature: 20 initial, 20/27 non-op); B- — Tibial Tunnel
PT-B autografts – More vertical
— 4.2 yr F/U: 90% return to sport, no LLD — Femoral Tunnel
• Aronwitz et al (AJSM 2000) — Minimal Notchplasty/ Over-the-Top Dissection
— 19 pts (skeletally immature >14 bone age, Achilles allo — Tight Tunnel Fit
— 2.1 yr F/U; 84% RTS; 97 Lysholm; 1.7mm KT1000 – 8-9 mm
— Femoral Fixation
Problems
– Continuous Loop Endobutton
• Small Series
— Tibial Fixation
• Growth Remaining
– Bioabsorbable Interference Screw/ Post
— Chronological Age
— Video Journal of Orthopaedics (6/06)
– Not Skeletal Age
– Not Physiological Age Prepubescents
— Tanner 4 • Technique
— MacIntosh 2 variation
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
170 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 171

– LJ Micheli — Risks: Nonoperative Treatment

— IT Band – Meniscal/ Chondral Injury
— Extra-Articular Tenodesis — Risks: Operative Treatment
— Over-the-Top – Growth Disturbance
– Minimal dissection • Understand Pediatric Knee Anatomy
— Over-the Front — Distal Femoral Physis & Over-Top
– Intermeniscal Ligament — Proximal Tibial Apophysis

S Y M P O S I A P E D I AT R I C S
— Fixation — Avoid Hardware/ Bone across Physis
• Technique
Physeal-Sparing Combined Intra/ Extra- Articular ACLr with
— Adolescents: Transphyseal Hamstrings
IT Band
— Prepubescents: Physeal-Sparing ITB
• Kocher et al (J Bone Joint Surg, 2005)
— 44 pts (10.3 yrs old (3.6-14.0)) Consequences of Pediatric Knee Injuries
— 5.3 yr follow-up (2.0-15.1) • ACL Reconstruction
— 4.5% revision rate (4.7 & 8.3 yrs) — Stiffness, Pain, Retear Graft
— IKDC: 96.7 + 6.0 — Arthritis
— Lysholm: 95.7 + 6.7 • Meniscal Injury
— 21.5 cm growth (9.5 – 118.0) — Complete Menisectomy: Arthritis
— No growth disturbance — Partial Menisectomy: ?
— Video Journal of Orthopaedics (3/06) — Discoid Lateral Meniscus: ?
• Chondral Injury
Pediatric Athlete
— Cartilage Injury: Arthritis
– “Child is not a little adult.”
— OCD: Arthritis
– “Child athlete is not a little adult athlete.”
• ? Long-Term Followup
Recommendations
• Know Patient’s Growth Remaining
• Shared Decision Making

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
171
SYM 07:Layout 1 1/12/07 11:40 AM Page 172

JUVENILE OSTEOCHONDRITIS DISSECANS OF THE KNEE:

CURRENT CONCEPTS IN EVALUATION AND MANAGEMENT
Theodore J. Ganley, MD
S Y M P O S I A P E D I AT R I C S

OSTEOCHONDRITIS DISSECANS OF THE KNEE Negatives

Fibrocartilage – unpredictable durability
Background/Key facts
Non-weightbearing protocol
Disorder of the subchondral bone
Subchondral plate breach
Secondarily affects overlying articular cartilage
ACI delay for 9 mos.
Can lead to cartilage separation and fragmentation
Indications (0.5cm or larger)
Repetitive microtrauma can lead to microfractures that
Grade IV possibly grade III lesions
cause focal ischemia or alteration of growth
Intact “shoulders” / Perimeter contained
Prognosis depends on status of growth plate
Higher demand pts-smaller lesions
Lateral aspect of the MFC most common site, up to 75%
Lower demand pts-larger lesions
32% incidence rate of moderate to severe osteoarthritis after
Complications
34 yrs followup
Hematoma
Clinical Presentation Stem cell migration
Usually a stable lesion Vascular ingrowth
Patients report aching and activity-related knee pain local- Osteochondral graft (mosaicplasty)
ized at anterior aspect Periosteum grafts
Symptoms overlap with those from other causes Autologous chondrocyte implantation
+Wilson’s sign Goals
Fill defect with hyaline cartilage
Operative indications
Prevent progression of joint disease
Persistent symptomatic juvenile lesions (failed conservative
Function and symptomology
trial(s))
Considerations
Predicted physeal closure within 6-12mo
Successful in young patients with large articular
Symptomatic loose bodies
defects on the femur
Fragment detachment/non-union
Long-term evaluation needed over the lifetime of
Treatment of stable lesions these young patients
Goals Current Concepts—Microfracture vs. ACI
Enhancement of local blood supply Prospective outcome study showing similar clinical
Protected weight bearing results
Techniques Controversy
Antegrade arthroscopic drilling - Short Term Study
0.62mm smooth K-wires -Pathology superior with ACI
Perpendicular to joint surface Current and future directions
Holes several mm apart Collagen Scaffolds
Retrograde BMP’s/ Cytokines
0.62mm smooth K-wires Genetics
C-arm visualization
Non-healed lesions
Repeat drilling
Chondroplasty
Treatment of unstable lesions
Fixation
Metal implant (pin or screw)
Bio-absorbables
Loose body/fragment removal
(creates full thickness lesion—see below)
Full thickness lesions
Messenchymal Cell Stimulation (Drilling, Microfracture
Abrasion)
Repair defects with fibrocartilage
Principally type I collagen
Component of type II, VI, and IX (hyaline types)
Positives
Technically simple
Single stage arthroscopic
Low morbidity
Cost effective

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
172 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 173

S Y M P O S I A P E D I AT R I C S
REFERENCES 11. Peterson, L.; Minas, T.; Brittberg, M.and Lindahl, A.: Treatment of osteochondritis
1. Twyman, R. S.; Desai, K.and Aichroth, P. M.: Osteochondritis dissecans of the dissecans of the knee with autologous chondrocyte transplantation: results at two
knee. A long-term study. J Bone Joint Surg Br, 73(3): 461-4, 1991. to ten years. J Bone Joint Surg Am, 85-A(Suppl 2): 17-24, 2003.

2. Wilson, J. N.: A diagnostic sign in osteochondritis dissecans of the knee. J Bone 12. King, P. J. Ganley, T.J. Lou, J.E. Gregg, J.R.: Autologous chondrocyte transplanta-
Joint Surg Am, 49(3): 477-80, 1967. tion for the treatment of large defects in the articular cartilage of the distal femur
in adolescent patients. American Academy of Orthopaedic Surgeons, 2003.
3. Cahill, B. R.and Berg, B. C.: 99m-Technetium phosphate compound joint scintig-
raphy in the management of juvenile osteochondritis dissecans of the femoral 13. Flynn, J.M. Kocher, M.S. Ganley, T.J. Osteochodritis Dissecans of the Knee. J.
condyles. Am J Sports Med, 11(5): 329-35, 1983. Pediatr. Orthop., in Press

4. De Smet, A. A.; Ilahi, O. A.and Graf, B. K.: Untreated osteochondritis dissecans of 14. Iobst, C., Kocher, M.S.: Cartilage Injury in the Skeletally Immature Athlete. In
the femoral condyles: prediction of patient outcome using radiographic and MR Mirzayan R (ed.): Cartilage Injury in the Athlete. New York: Thieme, in press.
findings. Skeletal Radiol, 26(8): 463-7, 1997. 15. Kocher, M.S.; DiCanzio, J.; Zurakowski, D.; Micheli, L.J.: Diagnostic performance
5. Pill, S. G.; Ganley, T. J.; Milam, R. A.; Lou, J. E.; Meyer, J. S.and Flynn, J. M.: Role of clinical examination and selective magnetic resonance imaging in the evalua-
of magnetic resonance imaging and clinical criteria in predicting successful non- tion of intra-articular knee disorders in children and adolescents. Am J Sports
operative treatment of osteochondritis dissecans in children. J Pediatr Orthop, Med, 29(3): 292-296, 2001.
23(1): 102-8, 2003. 16. Kocher, M. S., Micheli, L.J.; Yaniv, M.; Zurakowski, D.; Ames, A.; Adrignolo, A.A.:
6. O'Connor, M. A.; Palaniappan, M.; Khan, N.and Bruce, C. E.: Osteochondritis Functional and Radiographic Outcome of Juvenile Osteochondritis Dissecans of
dissecans of the knee in children. A comparison of MRI and arthroscopic find- the Knee Treated with Transarticular Arthroscopic Drilling. Am J Sports Med,
ings. J Bone Joint Surg Br, 84(2): 258-62, 2002. 29(5): 562-566, 2001.

7. Vonstein, D. W. N., H. Laor, T. et al.: Juvenile Osteochondritis Dissecans of the 17. Scioscia, T. N.; Giffin, J. R.; Allen, C. R. et al.: Potential complication of bioab-
Knee: Healing Prognosis Based on X-Ray and Gadolinium Enhanced MRI. sorbable screw fixation for osteochondritis dissecans of the knee. Arthroscopy,
Pediatric Orthopaedic Society of North America: 79, 2003. 17(2): E7, 2001.

8. Cahill, B. R.: Osteochondritis Dissecans of the Knee: Treatment of Juvenile and 18. Steadman, J.R.; Briggs, K.K.; Rodrigo, J.J.; Kocher, M.S.; Gill; T.J.; Rodkey, W.G.:
Adult Forms. J Am Acad Orthop Surg, 3(4): 237-247, 1995. Outcomes of microfracture for traumatic chondral defects of the knee: Average
11-year follow-up. Arthroscopy, 19(5): 477-484, 2003.
9. Anderson, A. F.; Richards, D. B.; Pagnani, M. J.and Hovis, W. D.: Antegrade
drilling for osteochondritis dissecans of the knee. Arthroscopy, 13(3): 319-24, 19. Thomson, N. L.: Osteochondritis dissecans and osteochondral fragments man-
1997. aged by Herbert compression screw fixation. Clin Orthop, (224): 71-8, 1987.

10. Aglietti, P.; Buzzi, R.; Bassi, P. B.and Fioriti, M.: Arthroscopic drilling in juvenile
osteochondritis dissecans of the medial femoral condyle. Arthroscopy, 10(3):
286-91, 1994.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
173
SYM 07:Layout 1 1/12/07 11:40 AM Page 174

ADOLESCENT PATELLO-FEMORAL DISORDERS

Carl L. Stanitski, MD

PATELLO-FEMORAL DISORDERS IAAKP : IMAGING

• Routine radiographs usually normal; Static study
Anterior Knee Pain; Patellar Instability
S Y M P O S I A P E D I AT R I C S

• CT Scan
ANTERIOR KNEE PAIN — Tilt/translation: quadriceps relaxed/contracted
• “The patella covers the condyles of the underlying bones in • Bone Scan : CRPS (Late)
well suited depressions--- • MRI: Not a substitute for a clinical examination
• Some call this bone the knee cap, some the millstone” — “New”Test: H and P
— Galen, 150 A.D.
IAAKP : Treatment
ANTERIOR KNEE PAIN • 80+% = Better with non-operative treatment
• Common site of complaints — Flexibility,strength, growth, time
• Macro vs micro trauma • Patient, parent reassurance
• Knee pain is hip pain until proven otherwise • Brace, taping
— Placebo; ?Proprioception
“CHONDROMALACIA PATELLA”
• Conversion of gross pathologic observation to poorly- IAAKP OVERUSE TREATMENT
defined clinical entity • Identify risk factor(s)
• Incorrect term • Modify risk factor(s)
• “Idiopathic” adolescent anterior knee pain (IAAKP) until a • Pain control-post diagnosis
specific diagnosis is made • Specific rehabilitation
• Maintenance therapy program
IAAKP
• Natural History IAAKP : Treatment
— Goodfellow et al: Untreated; excellent results at long- • If not responsive to program consider
term follow-up — CRPS
— No evidence of early arthrosis — Psychosocial problems
— “Headache of the knee” • IAAKP: Disease waiting for an arthroscope
— Burr holes /headache
IAAKP : DIAGNOSIS
— Specific indication
• Primary effort is to identify specific cause of pain if possible
— High complication rate
— Patellar instability; Overuse
— Intra-articular disorder IAAKP : Summary
— Referred pain • “Chondromalacia Patella” is the wrong diagnosis !!!
• Most can be done by clinical evaluation • IAAKP until diagnosis
• Pain etiology myriad
IAAKP: DIFFERENTIAL DIAGNOSIS
• Diagnosis is clinical, not by imaging or arthroscopy
• Multipartite patella
• Non-fatal condition
• Plica: Over diagnosis and treatment
• Activity modification, not elimination
• Patellar instability
• Osgood-Schlatter’s Dz; Tendinitis ACUTE PATELLAR DISLOCATION
• Complex Regional Pain Syndrome • Instability: Jumping, Direction Change Sports; Direct blow
from equipment, obstacles
IAAKP: Diagnosis-History
• Age; Gender Distribution
• Non-specific
— Population studied
— “Grab Sign”
— Not all un-athletic females
— Sitting, stairs
• Direct vs Indirect
• Overuse factors
• Initial vs Repeated
• Growth rate
• Beware of a teen-aged patient whose Mother talks more INSTABILITY: NOMENCLATURE
than they do ! • Mal-alignment = Static
• Mal-tracking = Dynamic
IAAKP : OVERUSE
— Both may be asymptomatic
• Training Errors: Too Much, Too Soon
• Instability : May be due to either or both
• Shoes, Surfaces
— Wide spectrum
• Running Bleachers, Stairs, Hills
• Strength Training: Squats, Weight Machines ACUTE PATELLAR INSTABILITY
• Past Studies
IAAKP : Diagnosis-Examination
• Short follow-up, limited clinical and XR data, varied treat-
• Gait; Alignment
ment, initial and repeat cases included; very few prospec-
• Flexibility; Laxity; Hip musculature strength
tive; none Level 1 or 2 evidence in children
• Range of Motion
• Reported “good” outcomes
• Patellar tracking
— 17-56% re-dislocation rates
• Local tenderness
— 69% not back to sport level
— Joint lines, Patella
• Muscle definition
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
174 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 175

PATELLAR DISLOCATION: History • Secondary Surgery

• Previous Injury, Treatment — Failed non-operative treatment
• Injury mechanism: • Pain, effusion
— Vast majority lateral, indirect — Repeat instability
• Medial: Iatrogenic-excessive lateral release or medial tight-
ACUTE PATELLAR DISLOCATION
ening
• If Loose Body, Arthroscopy
• Family History = 10% ? Genetic trochlear and patellar dys-
• Size, site, surface, bone

S Y M P O S I A P E D I AT R I C S
plasia
— Non-weight bearing, excise
PATELLAR DISLOCATION: P.E. — Weight bearing femur, trochlea: Fixation
• Accuracy : Pain, Anxiety • No lateral release
• Laxity : 30 patients ; Acute • Repair medial patello-femoral ligament
— No laxity=2.5x Articular injury
ACUTE PATELLAR DISLOCATION Treatment
• Opposite knee
• Individualized: Anatomic assets and liabilities
• Adductor tubercle = medial patello-femoral ligament ten-
• Re-establish 4 vector balance
derness, gap
• No isolated lateral release
• R/O ACL tear : = Mechanism
• Reconstruct PF ligament = undersurface of the VMO
PATELLAR DISLOCATION:Imaging • May need semi-tendinosis transfer to augment medial vector
• XR: Static Images-Dynamic Event: 4 views • Tibial tubercle rotationplasty for alignment in skeletally
• Osteochondral Injury mature
— XR = 5-30% • Combination of above
— Scope = 54-74%
ACUTE PATELLAR DISLOCATION
PATELLAR DISLOCATION Pathology • Poor Outcomes
• Medial Vector Loss — Loss of Medial Vector with Residual Instability
— MPF and MP Ligaments = 75% medial stability — Articular Shear Injury with Unrecognized Osteochondral
• Undersurface of VMO Lesion(s)
— Entire quadriceps weak
ACUTE PATELLAR DISLOCATION
— 4 vector balance loss
• ??? Return to Play
• Laxity; LE Alignment; +FH; Previous episode
• Full Motion
• Articular injury
• No Effusion or pain
ACUTE PATELLAR DISLOCATION Treatment • Strength,Endurance = to normal side for hip flexors, hip
• 90% Spontaneous reduction abd, quadriceps, hamstrings, gastrocnemeus/soleus
• Atraumatic Reduction • Full speed agility drills
— Prone = hamstrings relaxed • Sport specific tasks
— Sedation
ACUTE PATELLAR DISLOCATION
— Aspiration: Pain, Fat/effusion
• Not as good outcomes as older literature reports
• XR/ Loose Body
• Outcome related to medial vector competence and articular
ACUTE PATELLAR DISLOCATION Treatment injury
• Reduced; No Loose Body/X-ray — Mild vector loss = good result
• Immobilizer; Re-examine in 3-5 Days — Poor = medial vector loss + articular damage
• If motion restored, effusion decreased, comfortable
PATELLAR DISLOCATION
• Therapy: Limited Motion; Strength; PWB; Not
• “…when I searched along past and present authors for the
Immobilizaton
origins and doctrines accepted today concerning dislocation
• Re-evaluate in 3-5 days
of the patella, I was surprised to find among them such a
• If still not better, MRI
dearth of facts with such an abundance of opinions.”
— Osteo-chondral injury; PF ligament status
— Malgaigne. 1846
ACUTE PATELLAR DISLOCATION Treatment
• Primary Initial Surgery
— Repeat dislocation; + family history; high demand athlete
— OC loose body; Avulsion of PF ligament

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
175
SYM 07:Layout 1 1/12/07 11:40 AM Page 176

REFERENCES
S Y M P O S I A P E D I AT R I C S

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
176 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 177

S Y M P O S I A P E D I AT R I C S

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
177
SYM 07:Layout 1 1/12/07 11:40 AM Page 178

PEDIATRIC FRACTURES, COMMON PITFALLS

S Y M P O S I A P E D I AT R I C S

AND MANAGEMENT STRATEGIES (X)

Moderator: Kenneth J. Noonan, MD, Madison, WI (n)

A review of problems and complications that occur in pediatric trauma will be presented;
and methods to avoid, detect and treat complications will be discussed.

I. Challenging Finger Fractures

Peter M. Waters, MD, Boston, MA (n)

II. Untoward Outcomes in Elbow Fractures

David L. Skaggs, MD, Los Angeles, CA (a, b, e - Medtronics, Stryker Spine,
b - Synthes Spine)

III. Problems in Forearm and Wrist Fractures

Peter M. Waters, Boston, MA (n)

IV. Case Presentations of Upper Extremity Complications

Kenneth J. Noonan MD, Madison, WI (n)

V. Questions to the Panel from the Audience

VI. Complications from Hip Fractures and Dislocations

Kenneth J. Noonan MD, Madison, WI (n)

V. Pitfalls in Management of Femur Fractures

James F. Mooney III, MD, Charleston, SC (n)

VI. Dangers of Physeal Fractures about the Knee and Ankle

John M. Flynn MD, Philadelphia, PA (n)

VII. Case Presentations of Lower Extremity Complications

Kenneth J. Noonan MD, Madison, WI (n)

VIII. Questions to the Panel from the Audience

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
178 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 179

HAND AND FOREARM COMPLICATIONS

Peter M. Waters, MD

Forearm Fractures Monteggia Fracture Dislocation

Problems Basic Principle:

S Y M P O S I A P E D I AT R I C S
• Malunion Identify the Lesion
• Loss of motion • Inspect elbow and wrist joint
• Compartment syndrome • Radiocapitellar alignment
• Growth issues – Smith Sur Ob Gyn 1941
Age, fracture and treatment dependent – Sorren Acta Chir Scand 1958
Acceptable Reduction for Closed treatment? – Miles, Finley Injury 1989
Closed reduction problems – Gleeson J Accd Emerg Med 1994
• Poor reduction – Weisman, Rang, Cole JPO 1999
• Poor cast
Acute Monteggia:
• Wrong decision
Ulnar Stability
Acceptable Reduction? Treatment Options
Will it fix itself? • Closed Reduction
• Remodeling dependent on • Intramedullary Fixation
– age of patient • Open Reduction Internal Fixation
– proximity to physis • Open Reduction Radial Head
– amount/direction of deformity Closed Reduction
• corrects up to 0.9degrees/month (Frieberg) • Classic textbook teaching
• “Pediatric Monteggia fractures can be treated with closed
Acceptable Reduction?
reduction, cast immobilization”
• No malrotation
• Treatment principle accurate for plastic deformation, green-
• Malangulation > 20 degrees in younger child
stick fractures
• Malangulation >10-15 degrees in older child or in proximal
Intramedullary Fixation
third radius fractures
• Stabilizes ulna fracture…
• Kasser principle of “ugliness”
• In turn, stabilizes radial head dislocation
Open Reduction Indications • Principle applies to transverse, short oblique fractures
• Operator dependent
Open Reduction Internal Fixation
– Unstable
• Thompson… CORR 1984
– Irreducible
• Ring, Waters JBJS (B) 1996
– But if in doubt….
• Principle applies to long oblique, comminuted fractures
• Neurovascular compromise, open fractures
– Please do these emergently Open Reduction Radial Head
• Fix all these • Wise JBJS (A) 1941
– floating elbow, Galeazzi, Monteggia • Thompkins JBJS (A) 1971
– refracture • Morris JBJS (A) 1974
• Watson, Singer Injury 1994
Intramedullary Fixation
• Rare situation but does occur
• Increased use
• Problems Complications
– Difficult percutaneous reduction and fixation Failure to Detect Radial Head Dislocation
– Compartment syndrome • Smith Surg OB Gyn 1941
— Too many passes • Fowles.. JBJS (A) 1983
– Refracture • Tait, Salaiman Injury 1988
— Timing of hardware removal • Best JPO 1994
– Extensor tendon rupture • Gleeson, Beattie J Accd Emerg Med 1994
• Devanni Injury 1997
Single Bone Fixation
• Weisman, Rang, Cole JPO 1999
• Indicated for unstable fractures in 8-13 yr age
• Too often by good surgeons
• Converts unstable fracture to a greenstick equivalent
• Ulna intramedullary pin most often used Missed Lesion
• Problem of over-use with unstable radius • Focus on fracture only
• Incidence still very high in orthopedic and radiology litera-
Compartment Syndrome
ture despite published awareness
• Disportionate Pain
• Pain on Passive Stretch Complications
• Tense Compartment
Failure to Obtain Reduction
• Decreased Sensibility
• Increasing Analgesic Requirement Late Subluxation
(Bae,Waters,Kadiayla JPO 2002) • Weisman, Rang, Cole JPO 1999

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
179
SYM 07:Layout 1 1/12/07 11:40 AM Page 180

Mistaken for Congenital Dislocation – Phalangeal neck

• McFarland Br J Surg 1936 – Malrotation
• Key: recognition of problematic injuries
Conclusions
• Acute recognition imperative Examination
• Precise radiographic reading • The cornerstone for evaluating the complex from the simple
• Closed reduction for stable injuries injuries
– Plastic deformation • Observation
S Y M P O S I A P E D I AT R I C S

– Incomplete fractures – Cascade

• Ulnar Fixation for unstable fractures – Rotation
– IM rod for short oblque, transverse fxs • Palpation
– Plate/screw for long oblique, comminuted fxs – Helpful for assessing the scaphoid
Chronic Monteggia Reconstructiuon Examination
• Not as easy as some papers suggest Tendon, Nerve and Arterial Testing
• Multiple techniques described – Must be specific, thorough
• Each surgeon’s experience limited Mallet Fractures
• Not every lesion the same • Adolescent = adult
• Better to get it right the first time – joint must be reduced
• Refer these to those who do them often – Splint treatment
• skeletally immature
Radius Metaphyseal Fractures
– represents a physeal separation
• Reduction for >10 degrees mal-alignment
– nail bed injury
• Unstable fractures
• Frequent loss of reduction Pediatric Mallet:
(Proctor, Gibbons, Miller…) Germinal Matrix
Percutaneous Pinning Phalangeal Neck
• Initial angulation >30 degrees? • Severity Often Missed
• Initial displacement >50%? • Unstable Fracture
• Neurovascular compromise • Requires surgical treatment
• Associated elbow fracture Phalangeal Fractures
Radius Physeal Fractures Neck
• Pre-adolescent injury • Malunion
• Standard treatment closed reduction cast treatment • Subchondral Fossa Reconstruction
• Rare complications
Intra-articular
Radius Physeal Fractures
• Anatomic reduction
COMPLICATIONS • Towel-clip closed reduction, pinning
• Median Neuropathy, Acute Carpal Tunnel/ Compartment • Open reduction
Syndrome • Careful dissection to avoid AVN
• Growth Arrest
Phalangeal Fractures
Growth Arrest Intercondylar
• Ulnar Overgrowth • Malunion
• Ulnar carpal impaction
Phalangeal Fractures
• DRUG incongruity
Diaphyseal
• TFCC tear
• Assess rotation
• Treat all elements
– parallel nails
– Ulnar shortening osteotomy
– point to scaphoid
– Radial osteotomy +/-
– active flexion
– Arthroscopy, repair TFCC, chondral injury
– wrist tenodesis
(Waters, Bae JPO ’02)
Phalangeal Fractures
Median Neuropathy
Diaphyseal
• Contusion
• Malrotation
• Traction Ischemia
Metacarpal Fractures
• Acute Carpal Tunnel Syndrome
• Diaphyseal
• Pinning indicated
• Malrotation
Hand Injuries
Thumb Fractures
• The hand is the most commonly injured body part in the
• Base of metacarpal
child
• CMC joint: universal motion
• Most fractures are benign and require little treatment (75%)
• Outstanding remodeling with cast treatment
• Recognition of problem injuries is essential
SH III Fracture Thumb
Recognize problem injuries
Problem fractures: Dislocations:
– Open Interphalangeal (PIP/DIP)
– Intra-articular • Concentric reduction
– “Seymour’s”
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
180 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 181

Dislocations: • Ring finger most common

Metacarpal-phalangeal • Diagnose, splint, early follow-up
• Delayed treatment -> complications
Irreducible (complex)
Open tendon injuries
– bayonet (parallel) alignment of MC and phalanx
Careful examination of wound, tendon function
– require open reduction
Small wounds mask deeper zone of injury
Closed tendon injuries* Multiple tendon lacerations, complex wounds

S Y M P O S I A P E D I AT R I C S
“Jersey finger”
• FDP avulsion off P3 +/- bony fragment

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
181
SYM 07:Layout 1 1/12/07 11:40 AM Page 182

UNTOWARD OUTCOMES IN ELBOW FRACTURES

David L. Skaggs, MD

Know your anatomy Medial comminution

3 Golden Rules • special case requires pinning or heals in cubitus varus
S Y M P O S I A P E D I AT R I C S

1. anterior humeral line intersects the capitellum

Timing
2. Bauman’s angle >10 degrees
• studies promoting waiting are retrospective and dangerous
3. radius points to the capitellum in all views
— poor evidence
Little growth about elbow • use clinical judgement
• 20% of humerus is distal physis
Compartment syndrome –still occurs
• Do not rely on remodeling
• undue swelling, delay in treatment, skin puckering, ecchy-
Supracondylar Fractures mosis, neurovascular injury
Neurologic injury • elbow flexion > 90 degrees = increased compartment pres-
• Roughly 20% sure and decreased arterial flow
• AIN most common
Lateral Condyle Fractures
• Generally neuropraxia, does not require exploration
• Get oblique views – most displacement
• Returns within 3 month
— at presentation and follow-up
Vascular injury • prolonged immobilization necessary at times during closed
• roughly 20% treatment
• usually improves with fracture reduction • >2mm displaced, operative
• do NOT do pre-op arteriogram, needless delay • open vs. closed -arthrogram vs. MRI
• if pulse is present pre-reduction, but not post-reduction, • Late presentation – more rigid fixation
assume artery is trapped in fracture site. — no posterior dissection
• if hand is well-perfused but pulseless pre- and post-op, • Complications will occur
observation in hospital is probably OK — lateral overgrowth, spurs, delayed union
Pin Configuration Olecranon Fractures
• Lateral entry pins • Missing another fracture - >50% associated fractures
— avoids iatrogenic ulnar nerve injury • Avulsion pathognomonic for osteogenesis imperfecta
— adequate fixation if done correctly
Radial Head Fractures
— 3 pins for Type III, 2 pins for Type II
• Minimally invasive as possible
• Medial entry pin
— closed reduction > percutaneous K-wire > freer > formal
— may injure ulnar nerve directly or by tightening soft-tis-
open
sue around nerve
• early therapy
— place when elbow extended to remove ulnar
• set parental expectations
• Prospective study found little difference
Monteggia Fractures
Type II
• missed diagnosis
• generally pin
— ulna is ruler straight
• high rate of loss of reduction (28%) and poor outcome
• reduce the ulna
(8%) if treated closed
• try to avoid a transcapitellar pin

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
182 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 183

PEDIATRIC HIP FRACTURES

Ken Noonan MD

Pediatric Hip Fractures Neonatal Epiphysiolysis

• Rare • Separation Growth Cartilage

S Y M P O S I A P E D I AT R I C S
• Difficult to Treat — Traumatic Delivery (Breach)
• Fraught With Complications • PE: External Rotation, Shortened, Pseudoparalysis
— 60 % Complication Rate • Radiographs: Proximal and Lateral Displacement
— Potential for Long-Term Disability • Ddx: DDH, Septic Arthritis
• Any Question ==> Refer — Aspiration and Arthrogram
• Skin Traction and Casting
Mechanism
• Rare, 1% of Pediatric Fractures Type 1 Fractures - Traumatic
• Traumatic Birth - Proximal Epiphysiolysis • Rarest of Hip Fractures
• High Energy Injury - Femoral Neck Fx. — Very Young (? C. Abuse) or Adolescent
• MVA, Auto vs. Pedestrian, Fall • 50 % of Time With Epiphyseal Dislocation
• Not Impacted, Prone to Displace — A - Without Dislocation
• Pathologic Fracture — B - With Dislocation
• May need CT Scan to Assess Direction and Degree
Embryology - Development
Displacement
• Common Cartilage Analage
• Ossification Center Femoral Epiphysis Treatment of Type 1
— 4 - 8 Months • < 2 y.o.a. (C. Reduction - Spica Cast)
— 15 % of Final Limb Length • >2 y.o.a
• Ossification Trochanteric Apophysis — Open or Closed Reduction
— 4 Years — Approach in Direction of Dislocation
• Percutaneous Pinning
Blood Supply of Femoral Head
— Smooth Pins Younger Patients
• Ligamentum Teres
— Threaded Pins Older Patients
— Minimal Until 8 y.o.a (Max 20 %)
• Spica Cast (6 to 12 weeks)
• Metaphyseal Blood Supply (Present at Birth)
— None (4 y.o.a. to Growth Plate Closure) Treatment of Type 2
• Retinacular Vessels • Transverse Cervical
— Prominent by 3 to 4 years of age • Open or Closed Reduction
— Major Blood Supply Immature Hip — Watson-Jones Approach
— At Risk with Fracture Displacement • Percutaneous Pinning In all cases
— Threaded Pins
— Avoid Crossing the Physis unless Poor Fixation
Classification System Delbet
• Spica Cast (6 to 12 weeks)
• Type 1 - Trans-Epiphyseal 8%
• Type 2 - Transverse Cervical Treatment of Type 3
— Most Common 45 - 50 % • Cervico-Trochanteric
• Type 3 - Cervico-Trochanteric • Non-Displaced
— 2nd Most Common 30 - 35 % — May Cast with Very Close FU
• Type 4 - Inter-trochanteric — When in Doubt - Pin
— Lowest Complication Rates 15% • Displaced
— Open or Closed Reduction
Timing of Treatment
— Threaded Pin or DHS (Distal Fx.)
• Orthopeadic Urgency
• Spica Cast (6 to 12 weeks)
— Displaced Fractures
— Types 1- 3 Treatment of Type 4
• Reduction and Stabilization ASAP • Intertrochanteric
• Prompt Treatment May ⇓ Complication Rates • Non-Displaced
— May Cast “As is.” with Very Close FU
Closed Reduction
• Displaced
• Goal: No Varus and 10 -20 % Max. Disp.
— Traction and Casting vs. Operative Stabilization
• Fracture Table
— Dynamic Hip Screw vs. Multiple Pins
— Gentle Closed Reduction
— Minimal Traction Hardware
— Mild Abduction <3 Smooth Pins
— Mild Internal Rotation 3-7 4.0 - 4.5 Cannulated
7 -8 6.5 to 7.0 Cannulated
Open Reduction
• Pre-Drill and Tap
• Watson - Jones
• Consider Titanium Pins
• Anterior – Lateral
• DHS in Intertrochanteric Fracture

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
183
SYM 07:Layout 1 1/12/07 11:40 AM Page 184

Possible Complications — Swiontkowksi, J. Trauma 0/6

• 60 % Complication Rate — Boitzy 0/11 Type 2
— Avascular Necrosis • No Change in AVN Rates
— Nonunion — Gerber, Orthop. Trans, 1985
— Malunion — 28 Fractures, 7 Centers, Early Open ORIF
— Premature Physeal Arrest — 30 % Incidence in 28 Type 2 and 3’s
• LLD — 50 % in Type 2’s
S Y M P O S I A P E D I AT R I C S

• Trochanteric Overgrowth
Malunion
• Varus or Valgus Deformity with Growth
• Varus
Avascular Necrosis — Noted in 20%
• Usually Noted by 9 Months — Malalignment or Growth Arrest
• Up to 43 % Overall — ⇑ Incidence in Conservative only Management and Type
— Type 1 - 80 - 100 % Type 2 - 50 % 2 Fractures (Pin all Type 2)
— Type 3 - 25 % Type 4 - 15 % • Treatment
• Increased Prevalence — Observation
— Type 1 with Dislocation — Osteotomy
— Increased Initial Displacement – Older Children with < 110 degrees of Varus
— Older Children
Nonunion
Avascular Necrosis Ratliff • 5-8%
• Type 1 • Failure to Obtain and Maintain Reduction
— Most Common and Most Severe • Treatment
• Type 2 — Bone Graft
— Partial Antero-lateral Involvement — Osteotomy
• Type 3 — Growth Abnormalities
— Rare
Premature Physeal Closure
• Surgical Treatment
• 10 - 60 %
— Osteotomy, Bone Graft, Salvage Operation
• 2 ° to AVN, Pin Placement or Stimulation
Evacuation of Hematoma • Limb Length Discrepancy
• Arthrotomy — < 3 cm, Unless AVN
• Aspiration • Trochanteric Overgrowth
• Theoretical: • Partial Arrest - Progressive Varus or Valgus
— Decreased Intra-capsular Pressure • Variable Treatment
— Decreased AVN Rates
Hardware Removal
Evacuation of Hematoma • 9 to 12 Months after Surgery
• Decreased AVN Rates • AVN (United Fracture)
— Hoekstra, JPO 1993

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
184 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 185

FEMORAL SHAFT FRACTURES – MANAGEMENT

James F. Mooney, III, MD

“Non-Operative” Management ¬ Use of mismatched nail diameters (do not do

• Immediate / Early spica versus traction and delayed casting this!)

S Y M P O S I A P E D I AT R I C S
— Use of traction becoming far less common in any age – Refracture after nail removal – wait 6-12 months to
group remove
• Immediate / Early Spica – Knee pain / decreased ROM – minimize by:
— Indications ¬ Leave ends flush against the metaphyseal flare
– </= to 4 yo (remember Pavlik for pts </= 1 yo) ¬ Don’t leave ends of the nails distal to the physis
– < 2-3 cm of initial shortening • External Fixation
– closed injury / no significant comminution / stable fx — Indications
– minimal associated polytrauma – Unstable fx, significant soft tissue injury, gross con-
— Methods tamination, rapid placement for an unstable patient
– 90/90 cast vs < 90/90 positioning – Less commonly used for routine fx at this time
— Acceptable alignment — Complications
– < 2-3cm of shortening – Refracture – up to 21% in the literature. Can try and
– < 10-15 degrees varus/valgus/extension/flexion minimize by:
— Complications ¬ Avoid anatomic reduction of transverse fx
– LLD / Angular deformity ¬ Dynamization / early weightbearing
¬ Conscientious followup – wedging / cast change ¬ Wait for at least 3 cortices prior to removal
¬ Valgus mold on the lateral thigh - minimize the ¬ Limit activity / immobilize post removal
inevitable varus drift – Limited knee ROM
¬ Manage LLD toward the end of growth with con- ¬ Flex knee at least 30 degrees when placing distal
tralateral epiphyseodesis pins and/or release the ITB at pin sites
– Skin problems – Pin tract infections
¬ Minimize with good cast care / Gortex liners ¬ Universal problem / No “best” pin care method
– Compartment Syndrome / Soft tissue injuries ¬ Usually treatable with po Abx
¬ Recent report (JPO:Sept/Oct 2006) – 9 cases • ORIF / Percutaneous “bridge” plating
¬ All 90/90 spicas — Indications
– Authors recommend avoiding 90/90 and initial – Can be used with just about any fracture pattern
short leg cast for intraop traction – Not indicated with significant soft tissue injury or
contamination
Operative Treatment
— Open approach – Problems
• Options
– Large exposure / scar / blood loss / hardware removal
— Flexible nails
— Bridge plating – Recent case series in JPO: Mar/Apr 2006
— External fixation
– Percutaneous / limited exposure / soft tissue sparing
— Reamed / Rigid nails
– An alternative to ex fix in unstable fx patterns
— ORIF / Bridge plating
– Need for hardware removal still a problem
• Indications
– Don’t use adult devices in children!
— > 4yo – skeletal maturity
• Rigid / Reamed IM Nails
— Utilize various methods based on
— Indications
– Fracture pattern /stability/soft tissue injury/polytrau-
– Larger patients / unstable fx pattern
ma
– Pyriformis entry nails not indicated with open physes
– Size of the patient
/ Trochanteric entry nails now recommended for use
• Flexible Nails – Titanium or Stainless
in skeletally immature patients
— Indications
¬ Multiple manufacturers make peds nails with
– Relatively stable fx pattern
diameters down to 5.5 – 6.5mm
– Low subtrochanteric region to mid 1/3-distal 1/3
— Complications
junction
– AVN of the femoral head
– No gross contamination
¬ Reported with pyriformis and trochanteric entry
– Pt weight < 99 lbs (Cincinnati data – POSNA 2004)
nails – JPO: Mar/Apr 1999
— Complications – Up to 62% in one study (Sink, et al
¬ No good answer to this problem. Usually segmen-
JPO 2005)
tal involvement
– Shortening – usually unstable fx patterns – May lead
– May heal with ROM / NWB
to nail protrusion distally
– Rotational osteotomy / VFFG prior to collapse /
– Angular deformity
THA / Fusion
¬ Large patients / poor canal fill (need 70-80%)
– Greater trochanteric growth arrest – coxa valga

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
185
SYM 07:Layout 1 1/12/07 11:40 AM Page 186

DANGERS OF PHYSEAL FRACTURES ABOUT

THE KNEE AND ANKLE
John M. Flynn, MD
S Y M P O S I A P E D I AT R I C S

Distal Femoral Physeal Fractures Problems • Unrecognized ligament injury (especially MCL)
• Misdiagnosis • Loss of reduction: if any instabilty, use internal fixation and
— vs. Ligament injury (8% have both) immobilization
— imaging and exam • Neurologic injury
— f/u implications (MCL vs. Physeal fracture) — Tibial nerve injury
— Injury missed when focused on adjacent long bone injury — Usually resolves after reduction
• Loss of reduction: if any instabilty, use internal fixation and • Vascular injury
immobilization — High risk with posteriorly displaced fractures
• Avoid septic arthritis from percutaneous pins — Popliteal artery is tethered to the proximal tibia
— Keep percutaneous pins out of the knee — Maintain high suspicion: document vascular exam on
— Anterograde pinning for SH I arrival
— If retrograde necessary, remove no later than 3-4 weeks — Routine angiography not mandatory
• Neurologic injury — Beware of reperfusion compartment syndrome
— Peroneal injury (anterior and medial displacement) • Physeal arrest
— Do EMG if nerve deficit persists more than 4-6 months — 10-20% incidence (not clear in literature)
• Vascular injury — Principles of treatment similar to distal femur
— Uncommon
Distal Tibial Physeal Fractures Problems
— Most likely with anterior displacement of epiphysis
• Diagnosis
— Beware of reperfusion compartment syndrome (rare)
— AP, lateral, mortise views
• Growth arrest
— CT scan helpful, especially for triplane and Tillaux frac-
— 25% to 50% incidence
tures
— Minimizing risk
– obtain after reduction
– prompt, gentle reduction
– assess articular congruency
– anatomic alignment of physis (SH III, SH IV)
• Delayed union: some SH III fractures
– remove interposed periosteum?
• Malunion
— MRI: 3-D spoiled gradient-recall echo sequence
— Rotational malunion after SH I, II fractures; usually exter-
— Remove implants at four months to permit clear MRI
nal rotation
evaluation
— Valgus deformity after SH II fracture
— Treatment
— Treatment
– excision
– rarely necessary (few functional deficits)
¬ if premature arrest <25-50% of physis
– significantangulardeformity:supramalleolarosteotomy
¬ define bony bar with CT scan
• Physeal arrest
¬ combined with corrective osteotomy if angulation
— 20% incidence (not clear in literature)
> 20°
— Usually SH III, IV fractures
– hemiepiphyseodesis
— SH II fractures: role of entrapped periosteum
– completion epiphyseodesis, epiphyseodesis opposite
— Leg length discrepancy rarely a problem
side
— Angular deformity may be a problem
Proximal Tibial Physeal Fractures Problems — Treatment
• Misdiagnosis: – physeal bar excision
— Injury missed when focused on adjacent long bone injury – osteotomy
— Partial or complete spontaneous reduction may have – completion epiphyseodesis
occurred
REFERENCES 8. Gruber, HE et al. Physeal fractures, part II: fate of interposed periosteum in a
1. Skaggs, D., Flynn, J.. Trauma about the knee, tibia, and foot. In: Staying Out Of physeal fracture. J Pediatr Orthop. 2002 Nov-Dec;22(6):710-6.
Trouble in Pediatric Orthopedics. David L. Skaggs and John M. Flynn. 9. Rohmiller, MT et al. Salter-Harris I and II fractures of the distal tibia: does mech-
Lippincott Williams and Wilkins, 2006. anism of injury relate to premature physeal closure? J Pediatr Orthop. 2006
2. Ilharreborde B, et al Long-term prognosis of Salter-Harris type 2 injuries of the May-Jun;26(3):322-8.
distal femoral physis. J Pediatr Orthop B. 2006 Nov;15(6):433-8. 10. Nenopoulos SP et al. Outcome of physeal and epiphyseal injuries of the distal tibia
3. Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg. 2002 with intra-articular involvement. J Pediatr Orthop. 2005 Jul-Aug;25(4):518-22.
Sep-Oct;10(5):345-55. Review. 11. Lalonde KA et al Traumatic growth arrest of the distal tibia: a clinical and radi-
4. Eid, AM et al Traumatic injuries of the distal femoral physis. Retrospective study ographic review. Can J Surg. 2005 Apr;48(2):143-7.
on 151 cases. Injury. 2002 Apr;33(3):251-5. 12. Cutler, L et al. Do CT scans aid assessment of distal tibial physeal fractures? J
5. Ecklund K, Jaramillo D. Imaging of growth disturbance in children. Radiol Clin Bone Joint Surg Br. 2004 Mar;86(2):239-43.
North Am. 2001 Jul;39(4):823-41. 13. Barmada, A. et al. Premature physeal closure following distal tibia physeal frac-
6. Close, BJ et al MR of physeal fractures of the adolescent knee. Pediatr Radiol. tures: a new radiographic predictor. J Pediatr Orthop. 2003 Nov-Dec;23(6):733-9.
2000 Nov;30(11):756-62. 14. Phan VC et al. Foot progression angle after distal tibial physeal fractures.J Pediatr
7. Thompson, JD et al Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop. 2002 Jan-Feb;22(1):31-5.
Orthop. 1995 Jul-Aug;15(4):474-8.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
186 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 187

SYMPOSIA PRACTICE MANAGEMENT

THE ORTHOPAEDIC SURGEON
AND INDUSTRY RELATIONSHIP:
CONFLICT VERSUS COLLABORATION (L)
Moderator: Joseph C. McCarthy, MD
(a, e - Stryker Orthopedics, Arthrex Corporation, Innomed, e - United Health Care)

This symposium will explore and deliberate the current environment regarding conflict of
interest between surgeons and industry.

I. Introduction
Joseph C. McCarthy, MD, Newton, MA (a, e - Stryker Orthopedics,Arthrex Corporation,
Innomed, e - United Health Care) and Stuart Weinstein, MD, Iowa City, IA (a - NIH,
c – Lippincott, Williams and Wilkins)

II. The Surgeon and Industry: Clinician’s Perspective

Lawrence Dorr, MD, Inglewood, CA (a, c - Zimmer)

III. The Surgeon and Industry: The AAOS Perspective

Richard Kyle, MD, Minneapolis, MN (a, c - DePuy, Zimmer,
a - Midwest Orthopaedic Research Foundation, Team Ortho)

IV. The Surgeon and Industry: Industry Perspective

Ned Lipes, Mawah, NJ (e - Stryker)

V. The Surgeon and Industry: AdvaMed Perspective

Christopher L. White, JD, Washington, DC

VI. The Surgeon and Industry: The Government Perspective

To be Determined

VII. Industry Representative Reactor Panel

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
187
SYM 07:Layout 1 1/12/07 11:40 AM Page 188

THE CLINICIAN AND INDUSTRY RELATIONSHIP:

SYMPOSIA PRACTICE MANAGEMENT

CONFLICT VERSUS COLLABORATION

Joseph C. McCarthy, MD

How did this come about? Central Concern

Pharmaceutical Companies and Physician: • Professional judgment about patient welfare improperly
Potential conflict of interest influenced by secondary interest (personal gain from
PhRMA relationship)
1972
Anti Kickback Statute Amount of Spending:
(Medicare, Medicaid) $12 billion/year on gifts and payments to physicians
Amended 1977, 1980, 1987 Tap Pharmaceuticals’ Lupron Case
$290m Criminal Fines
1990
$580m Civil Fines
False Claims Act
$100m for Whistle Blowers
Fines for fraudulent Bills
Lessons from the Tap Case
2002
• MD’s paid as consultants without return services
AMA, A.C.P., ACCME
• Free trips to resort seminars
issued guidelines for interaction
• Education grants given with no strings
1986 • MD’s no paper trail
Whistleblower Statute
Stakeholders
15 – 30% of recovered amount
Physicians
2002 Patients
PhRMA Medical Device Companies
(Pharmaceutical Research and Manufacturers of America) Federal Government -
issued H.H.S
Broad Code of Conduct O.I.G.
C.M.S. Etc
2003
Inspector General of H.H.S. Suggested References:
Guidelines issued to avoid liability Committee on Ethics
Rationale Committee on Professionalism
• PhRMA direct marketing on patient care
• Cost of Medicare Rx Drug Benefit
• Fraud & Abuse Laws supplant self-regulation ethics

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
188 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 189

THE CLINICIAN AND INDUSTRY RELATIONSHIP: CONFLICT

SYMPOSIA PRACTICE MANAGEMENT

VERSUS COLLABORATION
Joseph C. McCarthy, MD, Stuart L. Weinstein, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
189
SYM 07:Layout 1 1/12/07 11:40 AM Page 190

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
190 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 191

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
191
SYM 07:Layout 1 1/12/07 11:40 AM Page 192

UNIVERSITY PERSPECTIVE
SYMPOSIA PRACTICE MANAGEMENT

Stuart L. Weinstein, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
192 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 193

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
193
SYM 07:Layout 1 1/12/07 11:40 AM Page 194

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
194 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 195

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
195
SYM 07:Layout 1 1/12/07 11:40 AM Page 196

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
196 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 197

PHYSICIAN / INDUSTRY RELATIONSHIP

SYMPOSIA PRACTICE MANAGEMENT

Richard F. Kyle, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
197
SYM 07:Layout 1 1/12/07 11:40 AM Page 198

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
198 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 199

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
199
SYM 07:Layout 1 1/12/07 11:40 AM Page 200

THE CLINICIAN’S PERSPECTIVE

SYMPOSIA PRACTICE MANAGEMENT

Lawrence D. Dorr, MD

Each of the last four decades has had its own emphasis on the and more surgeons sought a relationship with companies and
progress of orthopedic surgery. Prior to 1960 there was little that many surgeons brokered this relationship according to the vol-
an orthopedic surgeon could do, except treat infection, treat ume of operations that they performed, which they deemed to
polio deformities, and fix fractures. The decade of the 1960s rev- be of value to the company. Companies became liberal in
olutionized orthopedics. This was the decade in which devices employing surgeons as consultants, sometimes for no reason
were developed for the treatment of musculoskeletal disease. other than to use their implants. Many surgeons and consult-
Charnley developed the total hip replacement for arthritis of the ants positively contributed to the betterment of orthopedic sur-
hip in the early 1960s and in the latter 1960s Gunston, at gery by helping design implants, and improving operations,
Charnley’s Institution, developed the first knee replacement which would therefore also be productive for the company, and
(polycentric). During this decade Harrington designed the this relationship was a valuable one for both sides. This decade
Harrington rods for spine deformities. In Switzerland, the Swiss emphasized the articulation surface which was more a function
developed trauma fixation devices and the value of the work of of improvement by engineers rather than surgeons so that there
Kuntscher in developing the intramedullary rod was recognized. was less demand for surgeon designers. Therefore, there was a
significant increase in consultants during this decade and very
In the decade of the 1970s surgeons learned to do these tech-
few new surgeon designers from those that had participated
niques and there were additional total hip designs that were
during the decade of the 1980s.
developed. There was a development of companies by busi-
nessmen who recognized the value of these orthopedic devices. The decade of the 2000s has concentrated more on the process of
Prior to the decade of the 1960s the orthopedic companies the operation and less on implants. This again has minimized the
(Zimmer and DePuy) had primarily designed splints and frac- necessity for surgeon designers. However, there has been a defi-
ture devices. In the decade of the 1970s cement technique was nite need for consultants to help in designing instrumentation for
further developed for fixation of the hip and knee devices and the new operations and for participating in the development of
the total knee replacement was refined by Townley and at The surgical techniques for the existing implants within small inci-
Hospital for Special Surgery (Ranawat, Insall, and Walker). The sions. The implant changes in this decade have more often been
Industry- surgeon relationship was confined to a few companies in knee implants than hip implants although there is currently a
and a few surgeons. push to develop hip implants that are shorter and easier to
implant in small incisions. The surgeon-Industry relationship in
The decade of the 1980s was the most productive, creative, and
this decade is under investigation by the government, mostly
innovative decade for the surgeon-industrial relationship. In
because of some of the questionable consultant relationships
this decade multiple companies were formed for the purpose of
developed in the decade of the 1990s. It is likely that a result of
designing, developing, and selling orthopedic devices: primari-
this investigation will be further restraints on the surgeon
ly hip and knee replacements, arthroscopy equipment, and
Industry relationship and a demand by the government that this
spine devices. Each company developed a relationship with a
relationship be productive for orthopedics and for the company.
surgeon designer to help them design their implants and to be
spokespersons for the company. Surgeon designers were mostly Throughout all these changes in each of these decades, the pri-
paid royalties and participated in the success of the implants mary source of funding for progress in orthopedic devices has
they designed. This was a decade in total hip and knee replace- been from industry. There has been no major money for devel-
ment in which cementless fixation was predominant. Osteolysis opment of devices from the NIH or from the universities.
was initially felt to be caused by cement disease and this gave Universities and training centers have profited from surgeon
urgency to the development of cementless devices. Toward the innovation and creativity because they take a certain percentage
end of this decade it was learned that osteolysis was particle dis- of the surgeon’s royalties when the surgeon is a member of that
ease and the rush to cementless devices slowed. This had an particular institutional staff. Some centers have put money back
effect on many of the small companies that were dependent on into that surgeon’s research, however, some do not. Therefore,
these devices for success and as these companies failed, or were without industry we would not have made the progress that has
bought, there was also a consolidation of surgeon designs. occurred in each decade. The life and the surgery of the ortho-
pedic surgeon would be more difficult and would be less
The decade of the 1990s brought a change in the surgeon-
rewarding. As long as industry is the only source of funding for
Industry relationship. Many of the small companies failed and
the research to improve these orthopedic operations, there will
the larger companies merged so that there were not the same
be a necessity for surgeon designers and consultants, but the
number of opportunities for surgeon designers. Surgeons now,
future will require that this relationship be conducted with the
however, had had the experience of working with companies
highest ethical standards.
and the economic opportunities that this work offered. More

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
200 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 201

PHYSICAN/INDUSTRY RELATIONSHIP

SYMPOSIA PRACTICE MANAGEMENT

Richard F. Kyle, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
201
SYM 07:Layout 1 1/12/07 11:40 AM Page 202

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
202 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 203

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
203
SYM 07:Layout 1 1/12/07 11:40 AM Page 204

SYMPOSIA PRACTICE MANAGEMENT

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
204 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 205

SYMPOSIA PRACTICE MANAGEMENT

MAINTENANCE OF CERTIFICATION© (O)
Moderator: Marybeth Ezaki, MD, Dallas, TX (n)

A new process for Maintenance of Certification (MOC)© is being implemented by the

ABOS. It will involve every AAOS member certified after 1985. This symposium will address
the reasons for the changes in the re-certification process and the collaboration between the
ABOS and the AAOS in designing a MOC program that will a productive, learning
experience for orthopaedic surgeons. The new requirements and timelines will be discussed
as well as suggestions for incorporating mandatory CME and patient surveys into your
planning. Representatives of the ABOS-AAOS task force will be available to answer
questions.

I. Introduction of Maintenance of Certification - what/why/when

Marybeth Ezaki, MD, Dallas, TX (n)

II. Collaborative Efforts between AAOS and ABOS

Francis B. Kelly, MD, Macon, GA (d - Johnson and Johnson)

III. Assessment of performance in Practice (case list, surveys)

Marybeth Ezaki, MD, Dallas, TX (n) and David G. Lewallen, MD, Rochester, MN (a, b,
c - Zimmer)

IV. CME and SAE - what the AAOS can do for you
David G. Lewallen, MD, Rochester, MN (a, b, c - Zimmer)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
205
SYM 07:Layout 1 1/12/07 11:40 AM Page 206

SYMPOSIA SHOULDER/ELBOW

TREATMENT OF ROTATOR CUFF DISEASE:

AN INTERNATIONAL PERSPECTIVE ON THE
BURDEN OF EVIDENCE (C)
Moderator: Jon J.P. Warner, MD, Boston, MA (n)

This symposium on rotator cuff disease will marry science with technique and technology,
bringing all elements onto the same page for the participant.

I. Whose RCT Should we Fix and Why should we Fix it?

Kenneth Yamaguchi, MD, Saint Louis, MO (a, c - Tornier, Zimmer, c - Arthrex)

II. The Scientific Basis for Rotator Cuff Repair

Christian Gerber, MD, Zurich, Switzerland (c - Zimmer, e - Storz)
Point-Counter Point: Why I believe my way is the best way to fix the rotator cuff:

III. Arthroscopic Rotator Cuff Repair: Proof of Concept-Double Row Repair

Hiroyuki Sugaya, MD, Chiba, Japan (n)

IV. Arthroscopic Rotator Cuff Repair: Proof of Concept- Single Row Repair
Pascal Boileau, MD, Nice, France (c - Tornier)

V. Arthroscopic Repair of Subscapularis Tears: Proof of Concept

Laurent LaFosse, MD, Annecy, France (n)

VI. Salvage: When there is nothing left to fix-Proof of Concept

Jon J.P. Warner, MD, Boston, MA (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
206 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 207

WHOSE ROTATOR CUFF TEAR SHOULD WE FIX,

AND WHY SHOULD WE FIX IT?

SYMPOSIA SHOULDER/ELBOW
Ken Yamaguchi, MD

I. General Comments – Shoulder pain is one of the leading unlikely to heal without surgical intervention.
sources of musculoskeletal disability in the United States. 2. There is good evidence that rotator cuff tears gradually
Rotator cuff disease is by far the most common etiology for progress in size over time.
shoulder problems and the prevalence of full thickness dis- 3. An increase in size of rotator cuff disease can lead to
ease in the elderly population ranges anywhere from 5- the development of pain.
50%. Given the importance of rotator cuff treatment, surgi-
III. Potential Chronic Changes to the Untreated Rotator Cuff
cal indications to date remain surprisingly unstandardized
Tear
and still controversial. At a fundamental level, surgical indi-
A. Increased rotator cuff tear size (retraction):
cation involves a consideration of the following issues:
1. Muscle atrophy
A. The goals of surgical versus non-surgical treatment:
2. Fatty infiltration
1. Pain relief
3. Tendon morphological deterioration
2. Functional Improvement
4. Degenerative articular changes
B. A balance or analysis of the risk and benefits of any treat-
ment intervention: IV.Operative Indications – As stated before, operative indica-
1. Non-surgical treatment - the risk and benefits of non- tions generally require a balancing or consideration of risk
surgical treatment have to be considered. and benefits. What is important here is that the surgeon not
2. Surgical treatment – the risks and benefits of surgical only considers the risk and benefits of operative treatment
treatment have to be considered. but they also consider the risk and benefits of non-operative
C. Rotator cuff healing potential – this is a relatively new treatment. Risks of non-operative include:
consideration, which overlaps with the above issues. A. Acquiring chronic changes as previously stated:
Rotator cuff healing may or may not be a likely result of 1. Chronic changes are not reversible in most instances
surgical intervention depending on the patient profile. 2. An opportunity to obtain healing of the rotator cuff
D. Patient Profile – Multiple patient clinical features need to may be lost
be considered in balancing the above considerations. 3. The more chronic, and more massive the rotator cuff
These include: tear the less predictable the functional result.
1. The amount and duration of pain
V. Rotator Cuff Repair Healing – The best information is that
2. The significance of the functional disability
rotator cuff healing is far less predictable and occurs and
3. The age of the patient
that failure rates occur at a much higher level than previous-
4. The biologic profile of the patient:
ly considered.
a. “Poor protoplasm”
A. The difficulty with previous literature is that the effect of
b. Systemic illnesses such as rheumatoid arthritis
healing has been transparent as many people without
c. History of smoking
healing can achieve good results.
d. Activity level of the patient
B. There are several factors, which may be important to
e. The use of specific medications such as steroids or
achieving healing of the rotator cuff:
non-steroidal anti-inflammatories
1. Operative technique
II. Natural History of Rotator Cuff Disease 2. Strength of the fixation
A. Etiology – many reports have shown rotator cuff disease 3. Area of bone/tendon apposition
results from a natural process of aging. The exact contri- 4. Performance of releases
bution on primary degeneration or extrinsic factors such 5. Age of patient
as impingement to this aging process is not known 6. Chronicity of the tear
although primary degeneration appears to be the more 7. Genetics
important cause. Factors, which support the intrinsic 8. General health of the patient
nature of rotator cuff disease, include: 9. Environmental factors
1. Development of most rotator cuff tears from an artic- a. smoking
ular side first b. activity level
2. Age-related – the age related distribution of rotator c. rehab
cuff disease C. The most important factor is probably biology
3. The fact that most rotator cuff disease occurs in a 1. Age – over 60 years of age
bilateral fashion 2. Chronic changes
4. The fact that most rotator cuff tears are actually 3. Size of the tear
asymptomatic
VI. Surgical Technique – surgical technique becomes an
5. There appears to be a relationship of family history to
extremely important factor in those patients for whom
the development of rotator cuff disease.
biology is not a limiting factor:
6. There is a strong probability that smoking affects your
A. Younger age
chances of acquiring rotator cuff disease.
B. Absence of significant chronic changes
B. Natural history of rotator cuff tear progression.
C. Acute rotator cuff tears of any size
1. There is no evidence that rotator cuff tears can sponta-
D. Very healthy patients
neously heal without surgery. In fact, they are highly
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
207
SYM 07:Layout 1 1/12/07 11:40 AM Page 208

VII. Surgical Indications – given all of the above considera- should again be maximized. There are no significant
tions surgical indications can be organized for three problems with prolonged non-operative treatment.
groups of people based mostly on the above considera-
IX. Surgical Strategy Based on Patient Profiles
tions and the risks of non-operative treatment:
A. Group 2 – These are patients for whom biology is best
A. Group 1 – These are patients who are not at risk of
SYMPOSIA SHOULDER/ELBOW

suited to obtain healing after rotator cuff repair. In this

obtaining irreversible changes if they are treated non-
case, it makes sense to provide the best operative con-
operatively. In other words, non-operative treatment of
struct possible:
any significant period will not result in an irreversible
1. Full release of contractures
risk. These patients do not have a risk of acquiring the
2. Strong mechanical construct such as Mason-Allen
chronic changes spoken of above.
sutures or mattress sutures.
1. Patients who have an intact rotator cuff
3. Double row fixation
2. Patients with very small partial thickness tears
B. Group 3 – These are patients for whom biology is proba-
B. Group 2 – These are patients who have a significant risk
bly the limiting factor regardless of surgical technique. In
of acquiring chronic or irreversible changes with a delay
this group, the goal may be more modest. Instead of try-
in surgery. These are patients for whom a “bridge can be
ing to obtain a healed cuff, the goal may be more reason-
burned” if there is a surgical delay. They include:
able to change a symptomatic to an asymptomatic cuff
1. Patients with small or medium sized tears
tear. In this group of patients, from a surgical standpoint:
2. Acute tears of any size
1. A double row fixation may not be possible and proba-
a. these usually are tears that follow a distinct signifi-
bly will not change the chances of healing.
cant injury and are within a three month period.
2. A conservative approach to surgery should be consid-
3. Very large painful degenerative partial tears
ered including:
4. Tears of any size where the MRI or imaging study
a. no decompression
show that good tendon and muscle quality still exists.
b. no detachment of the deltoid
5. Tears in younger patients (less than 60 years old)
C. Group 3 – These are patients who have already realized X. Summary - From a treatment rationale standpoint, Group 1
chronic irreversible changes. These are patients for whom patients have a small risk with conservative treatment and a
“the bridge has already been burned.” They include: good chance for success with non-operative methods. If sur-
1. Tears in elderly patients greater than age 70 gery is performed, a rotator cuff repair is generally not
2. Patients with large or massive rotator cuff tears with required. Group 2 – these are patients with a significant risk
chronic changes by conservative treatment. The patient should generally pro-
ceed towards early surgery and surgical and rehabilitation
VIII. Timing of Surgery – Given the organization of non-oper-
methods should be aimed at maximizing the probability of
ative risks given above, the timing of surgery can be dic-
healing of the rotator cuff. This includes conservative rehab
tated by the risk for acquiring irreversible changes. Thus:
and secure broad-based fixation of the cuff. Group 3 – these
A. Group 1 – Patients for whom non-operative treatment
are patients that have a small risk with conservative treatment
can be maximized. You should error towards non-opera-
and thus, non-operative measures should be maximized. If
tive treatment in these patients. A high success rate with
an operative treatment is required, then the risk of the proce-
non-operative treatment should be expected.
dure should be kept small. A decompression should not be
B. Group 2 – Patients for whom early surgical treatment is
performed and the deltoid should not be harmed. Prolonged
probably warranted. Non-operative treatment in these
cases, trying to obtain extra fixation of the cuff is probably
patients may expose them to significant risks.
not warranted, and probably does not help ultimate healing.
C. Group 3 – Patients for whom non-operative treatment

REFERENCES 11. Bergenudd H, Nilsson B. The prevalence of locomotor complaints in middle age
1. Roy A, Dahan T. Rotator Cuff Disease. (Accessed September 16, 2005, at and their relationship to health and socioeconomic factors. Clin Orthop 1994;
http://www.emedicine.com/PMR/topic125.htm). 308:264-270.
2. Chard MD, Hazleman R, Hazleman BL, King RH, BB. R. Shoulder disorders in 12. Stenlund B, Goldie I, Hagberg M, C. H. Shoulder tendinitis and its relation to
the elderly: a community survey. Arthritis Rheum. 1991; 34:766-9. heavy manual work and exposure to vibration. Scand J Work Environ Health
1993; 19:43-9.
3. Wendelboe AM, Hegmann KT, Gren LH, Alder SC, White GL, Jr., Lyon JL.
Associations between body-mass index and surgery for rotator cuff tendinitis. J 13. Hellsing AL, Bryngelsson IL. Predictors of musculoskeletal pain in men: A twen-
Bone Joint Surg Am 2004; 86-A:743-7. ty-year follow-up from examination at enlistment. Spine 2000; 25:3080-6.
4. Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness 14. Mosley LH, Fineseth F. Cigarette smoking: Impairment of digital blood flow and
rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis 1995; 54:30-1. wound healing in the hand. Hand 1977; 9:97-101.
5. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on mag- 15. Leow YH, Maibach MI. Cigarette smoking, cutaneous vasculature, and tissue oxy-
netic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995; gen. Clin Dermatol 1998; 16:579-584.
77:10-5. 16. Prickett WD, Teefey SA, Galatz LM, Calfee RP, Middleton WD, Yamaguchi K.
6. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful
asymptomatic shoulders. J Shoulder Elbow Surg 1999; 8:296-9. postoperatively. J Bone Joint Surg Am 2003; 85-A:1084-9.
7. Leino-Arjas P. Smoking and musculoskeletal disorders in the metal industry: a 17. Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K.
prospective study. Occup Environ Med 1998; 55:828-33. Detection and quantification of rotator cuff tears. Comparison of ultrasono-
graphic, magnetic resonance imaging, and arthroscopic findings in seventy-one
8. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. consecutive cases. J Bone Joint Surg Am 2004; 86-A:708-16.
Ultrasonography of the rotator cuff. A comparison of ultrasonographic and
arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 18. Hill AB. The environment and disease: association or causation? Proceedings of
2000; 82:498-504. the Royal Society of Medicine 1965; 58:295-300.
9. Itoi E, Minagawa H, Lonno N, et al. Relationship between smoking and rotator 19. Yamaguchi K, Ditsios K, Middleton W, Hildebolt C, Galatz L, Teefey S. The
cuff tears. J Shoulder Elbow Surg 1996; 5:S124. demographic and morphological features of rotator cuff disease. A comparison
of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am
10. Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smok- 2006;88:1699-1704.
ing habits on the results of rotator cuff repair. J Shoulder Elbow Surg 2004;
13:129-32.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
208 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 209

THE SCIENTIFIC BASIS OF ROTATOR CUFF REPAIR

Christian Gerber, MD

SYMPOSIA SHOULDER/ELBOW
Do rotator cuff repairs heal? does it matter? Factors inherent in the tendon tear associated with poor healing
Although satisfactory clinical results after failed rotator repairs potential are: chronic tear with chronic static superior subluxa-
are well documented, the functional outcome is better if the tion on anteroposterior radiographs,2,9,13,34 advanced fatty infil-
repaired tendons heal. Therefore structural healing remains a tration of the affected muscle.9,14,35
major goal if high functional demands are to be satisfied.
There is sufficient experimental and clinical evidence to suggest
Currently, the expected rate of structural healing of the muscle–
that optimal mechanical fixation using appropriate sutures,
tendon–bone unit after full thickness rotator cuff tendon tear
suture grasping and tendon to bone fixation techniques are
and repair ranges from 50 to 90%. The success rate depends
associated with a higher healing rate.9,25,36-38 Healing occurs from
mainly on patient and tear type selection: Adequately per-
bursal and from cells originating from the bony footprint.39
formed open or arthroscopic repairs of single tendon tears with-
Vascularity of the tendon stump appear not to be critical.40
out marked retraction and fatty infiltration of the involved mus-
Trimming of the tendon stump may therefore be unwise. A deep
cle in young non-smokers heal with a probability of at least 90
bone trough weakens the insertion site and requires advancing
percent. Conversely, massive, retracted tears associated with fatty
the tendon more laterally for reattachment and thereby leads to
infiltration of no less than Goutallier stage 2 in smokers of more
increased repair tension.27,36,41,42 Intraoperatively, the footprint
than 65 years have a probability of healing of less than 25%.
should probably be debrided to allow release of marrow derived
Rotator cuff repair is clinically successful with comparable cells into the repair area and resection of the bursa must be
results using contemporary open and arthroscopic techniques 1- regarded as negative in view of the findings of Uhthoff et al.43-45
13. As opposed to the almost universal clinical success, tendon to
Pre-46-46 and postoperative administration of steroids and nons-
bone healing is only obtained in between less than 50 and
teroidal anti-inflammatory drugs has been shown to be detri-
approximately 90% of the operated shoulders.3-5,8,9,11,13-15
mental and should probably be replaced by regional anesthesia
Despite documented structural failure, clinical outcome is often
or pain relieving drugs not inhibiting cyclooxigenase 2{Cohen,
good or excellent.4,8,9,16 Yet, function and specifically recovery of
2006 #4989}47,48,48
strength are significantly better if the repairs heal.1,4,9,11 Structural
healing of a repair is also associated with less progression of Protection of a repair allowing only limited loading has proven
structural, degenerative changes in muscle, tendon and joint to be superior to unrestricted loading of a tendon repair25,49-52 or
surface than failure of healing.4,9,16 Furthermore there is ample full immobilization.
experimental and clinical evidence that after tendon tear, the
Personal experience suggests that diabetes, stiffness of the shoul-
muscle-tendon bone unit undergoes rapid degeneration which
der and rheumatoid disease with advanced possibly steroid
makes successful repair more difficult and healing less proba-
coinduced osteopenia are also risk factors for healing.
ble.16-28
What are the limiting factors to get the tendon to heal?
What factors affect the healing rate of rotator cuff tendon
Repair techniques have evolved and eliminated suture, tendon
repairs?
grasping techniques, techniques of tissue mobilization and ten-
Healing is adversely affected by advanced age (> 65 years),
don to bone fixation as limiting factors. With current techniques
smoking, chronic joint changes such as static superior subluxa-
the limits of repair and healing are in biological tissue quality:
tion of the glenohumeral joint with an acromiohumeral dis-
Severely osteopenic bone, thin, weak, brittle tendons, atrophied,
tance of ≤ 7 mm, fatty infiltration of the affected muscles of ≥
inelastic muscles with advanced fatty infiltration and fibrosis
stage 2 of Goutallier and advanced osteopenia of the humeral
have become the limiting factors which need to be addressed
head. In addition, suboptimal surgical technique (poor tissue
with new technologies and methods.
fixation, excessive trimming of tendon stump(s), devasculariza-
tion (bursal resection), excessive repair tension, deep trough), Previous work and industrial developments in fixation tech-
pre- or postoperative medication (NSAIDs, Steroids) and niques have addressed the former limits of tendon repair:
unprotected postoperative use of the arm may be detrimental. sutures have been identified as the first possible weak link in the
Empirically, diabetes, chronic inflammatory rheumatoid dis- repair chain,37 but excellent sutures with extremely high tensile
ease, pre- (and post-) operative shoulder stiffness, non-compli- strength and resistance to even metallic eyelets of anchors have
ance and certain constitutional predispositions are considered solved this problem. Tendon grasping techniques have become
to be risk factors for non-healing. reliable in vitro and in vivo,9,25,37 and tendon to bone repair,
although under some debate, appear reliable. Conversely the
The healing potential of a rotator cuff repair decreases with age.1
consequences of retraction of the musculotendinous
This goes along with the very well established increase in preva-
unit17,19,21,23,26,53,54 can not yet be compensated for and the inelas-
lence of rotator cuff tears with advancing age and especially with
tic, retracted muscle tendon unit can without relevant tension
the increase in prevalence of large, symptomatic tears.29
be brought to a bony insertion which is weak and may take a
It is reasonable to infer that the factors associated with an prolonged period of time to recover from the disuse atrophy
increased prevalence of rotator cuff tearing at a defined age such induced by tendon disinsertion.23,27 It appears that new treat-
as a genetic predisposition30 or large lateral extension of the ment strategies involving biological approaches are necessary to
acromion31,32 are further factors which adversely affect the heal- restore the tissue quality of the muscle-tendon-bone unit to a
ing potential. level where repair becomes again possible unless tissue engi-
neering concepts preceede this evolution and allow de novo cre-
The adverse effect of smoking on tendons is considered to be
ation of functioning units.
established.33

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
209
SYM 07:Layout 1 1/12/07 11:40 AM Page 210

What are the causes of muscle atrophy and is it reversible in the process is halted and atrophy even partially reversed17. In
humans? an experimental model, Meyer et al54 have shown that atrophy
Fatty atrophy of the involved muscles is the hallmark of chron- mostly occurs by virtue of loss of fiber length rather than num-
ic rotator cuff tearing. It is irreversible and associated with repair bers of fibers or fiber diameter. Their concept of changes
failure and poor treatment outcome. The mechanisms of atro- induced by changes of the pennation angle has also allowed to
SYMPOSIA SHOULDER/ELBOW

phy and fatty infiltration are probably different in acute and quantitatively explain the observed fatty infiltration after
chronic tendon tears and both are superimposed in human myotendinous retraction. We currently believe that the architec-
rotator cuff tears. In acute tears, degree of atrophy and fatty infil- tural changes of the rotator cuff muscles condition atrophy and
tration are mediated by the loss of resistance to the contraction most importantly fatty infiltration. The relative shortening of
and are quantitatively associated with the degree of myotendi- the individual muscle fibers is much larger than the relative
nous retraction. In chronic tears in the elderly, muscular repair retraction of the myotendinous unit. Retraction of the
mechanisms may be impaired. Atrophy of an affected muscle myotendinous not only involves fatty, but also fibrotic iniltra-
may be halted by successful restoration of the muscle-tendon- tion with concomitant loss of elasticity25,26,54 so that the muscle
bone continuity. Conversely, fatty infiltration of an affected fibers can not be brought to length during a one step repair but
muscle increases even after successful repair and appears irre- much rather, the procedure exerts tension which may destroy
versible with current repair techniques if stage 1 has been the individual muscle fibers.60 It is felt that current repair con-
passed. cepts can not revert the internal architectural changes of the
muscle belly so that fibrosis and fatty infiltration can not be
Tendon desinsertion or tear is followed by rapid loss of muscle
addressed.
mass,25,54,55 fibrosis and fatty infiltration of the mus-
cle.17,19,21,24,54,56-59 As soon as side to side adhesions are formed,

REFERENCES 17. Barton, E. R.; Gimbel, J. A.; Williams, G. R.; and Soslowsky, L. J.: Rat supraspina-
1. Boileau, P.; Brassart, N.; Watkinson, D. J.; Carles, M.; Hatzidakis, A. M.; and tus muscle atrophy after tendon detachment. J Orthop Res, 23(2): 259-65, 2005.
Krishnan, S. G.: Arthroscopic repair of full-thickness tears of the supraspinatus: 18. Bassett, R. W., and Cofield, R. H.: Acute Tears of the Rotator Cuff. The Timing of
does the tendon really heal? J Bone Joint Surg Am, 87(6): 1229-40, 2005. Surgical Repair. Clin.Orthop.Rel.Res., 175: 18 --24, 1983.
2. Ellman, H.; Hanker, G.; and Bayer, M.: Repair of the Rotator Cuff. End-Result 19. Bjorkenheim, J.-M.: Structure and function of the rabbit's supraspinatus muscle
Study of Factors Influencing Reconstruction. J. Bone Joint Surg., 68-A: 1136 -- after resection of its tendon. Acta Orthop.Scand., 60:(4): 461 --463, 1989.
1144, 1986. 20. Carpenter, J. E.; Thomopoulos, S.; Flanagan, C. L.; DeBano, C. M.; and
3. Flatow, E. L.: Does Arthroscopic Rotator Cuff Repair Work? In Annual Meeting of Soslowsky, L. J.: Rotator cuff defect healing: a biomechanical and histologic
the AAOS. Edited by AAOS, San Francisco, AAOS, 2004. analysis in an animal model. J Shoulder Elbow Surg, 7(6): 599-605., 1998.
4. Fuchs, B.; Gilbart, M. K.; Hodler, J.; and Gerber, C.: Clinical and structural results 21. Coleman, S. H.; Fealy, S.; Ehteshami, J. R.; MacGillivray, J. D.; Altchek, D. W.;
of open repair of an isolated one-tendon tear of the rotator cuff. J Bone Joint Warren, R. F.; and Turner, A. S.: Chronic rotator cuff injury and repair model in
Surg Am, 88(2): 309-16, 2006. sheep. J Bone Joint Surg Am, 85-A(12): 2391-402, 2003.
5. Galatz, L. M.; Ball, C. M.; Teefey, S. A.; Middleton, W. D.; and Yamaguchi, K.: The 22. Fabis, J.; Kordek, P.; Bogucki, A.; and Mazanowska-Gajdowicz, J.: Function of the
outcome and repair integrity of completely arthroscopically repaired large and rabbit supraspinatus muscle after large detachment of its tendon: 6-week, 3-
massive rotator cuff tears. J Bone Joint Surg Am, 86-A(2): 219-24, 2004. month, and 6-month observation. J Shoulder Elbow Surg, 9(3): 211-6, 2000.
6. Gartsman, G. M.; Khan, M.; and Hammerman, S. M.: Arthroscopic repair of full- 23. Galatz, L. M.; Rothermich, S. Y.; Zaegel, M.; Silva, M. J.; Havlioglu, N.; and
thickness tears of the rotator cuff. J Bone Joint Surg Am, 80(6): 832-40, 1998. Thomopoulos, S.: Delayed repair of tendon to bone injuries leads to decreased
7. Gartsman, G. M., and O'Connor D, P.: Arthroscopic rotator cuff repair with and biomechanical properties and bone loss. J Orthop Res, 23(6): 1441-7, 2005.
without arthroscopic subacromial decompression: a prospective, randomized 24. Gerber, C.; Meyer, D. C.; Schneeberger, A. G.; Hoppeler, H.; and Von Rechenberg,
study of one-year outcomes. J Shoulder Elbow Surg, 13(4): 424-6, 2004. B.: Effect of tendon release and delayed repair on the structure of the muscles of
8. Gazielly, D. F.; Gleyze, P.; and Montagnon, C.: Functional and Anatomical Results the rotator cuff: an experimental study in sheep. J Bone Joint Surg Am, 86-A(9):
After Rotator Cuff Repair. Clin.Orthop.Rel.Res., 304: 43-53, 1994. 1973-82, 2004.

9. Gerber, C., Fuchs,B., Hodler,J.: The Results of Repair of Massive Tears of the 25. Gerber, C.; Schneeberger, A. G.; Perren, S. M.; and Nyffeler, R. W.: Experimental
Rotator Cuff. J. Bone Joint Surg., 82-A: 505-515, 2000. rotator cuff repair. A preliminary study. J Bone Joint Surg Am, 81(9): 1281-90,
1999.
10. Goutallier, D., Postel,J.M., Lavau,L., Bernageau,J.: Influence de la dégénérescence
graisseuse des muscles supraépineux et infraépineux sur le pronostic des répara- 26. Hersche, O., and Gerber, C.: Passive tension in the supraspinatus musculotendi-
tions chirurgicales de la coiffe des rotateurs. Rev. Chir. Orthop., 85: 668-676, nous unit after long- standing rupture of its tendon: a preliminary report. J
1999. Shoulder Elbow Surg, 7(4): 393-6., 1998.

11. Harryman, D. T.; Mack, L. A.; Wang, K. Y.; Jackins, S. E.; Richardson, M. L.; and 27. Meyer, D. C.; Fucentese, S. F.; Koller, B.; and Gerber, C.: Association of osteopenia
Matsen, F. A.: Repairs of the Rotator Cuff. Correlation of Functional Results with of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg,
Integrity of the Cuff. J. Bone Joint Surg., 73-A(7): 982-989, 1991. 13(3): 333-7, 2004.

12. Sperling, J. W.; Cofield, R. H.; and Schleck, C.: Rotator cuff repair in patients fifty 28. Thomazeau, H., Rolland, Y., Lucas, C., Duval, J.-M., Langlais, F.: Atrophy of the
years of age and younger. J Bone Joint Surg Am, 86-A(10): 2212-5, 2004. supraspinatus belly. Assessment by MRI in 55 patients with rotator cuff patholo-
gy. Acta Orthop. Scand., 67(3): 264-.268, 1996.
13. Walch, G.; Maréchal, E.; Maupas, J.; and Liotard, J. P.: Traitement des ruptures de
la coiffe des rotateurs. Facteurs de pronostic. 29. Yamaguchi, K.; Ditsios, K.; Middleton, W. D.; Hildebolt, C. F.; Galatz, L. M.; and
Rev.Chir.Orthop.Reparatrice.Appar.Mot., 78(6): 379-388, 1992. Teefey, S. A.: The Demographic and Morphological Features of Rotator Cuff
Disease. A Comparison of Asymptomatic and Symptomatic Shoulders. J Bone
14. Goutallier, D.; Postel, J. M.; Gleyze, P.; Leguilloux, P.; and Van Driessche, S.: Joint Surg Am, 88(8): 1699-1704, 2006.
Influence of cuff muscle fatty degeneration on anatomic and functional out-
comes after simple suture of full-thickness tears. J Shoulder Elbow Surg, 12(6): 30. Harvie, P.; Ostlere, S. J.; Teh, J.; McNally, E. G.; Clipsham, K.; Burston, B. J.;
550-4, 2003. Pollard, T. C.; and Carr, A. J.: Genetic influences in the aetiology of tears of the
rotator cuff. Sibling risk of a full-thickness tear. J Bone Joint Surg Br, 86(5): 696-
15. Sugaya, H.; Maeda, K.; Matsuki, K.; and Moriishi, J.: Functional and structural 700, 2004.
outcome after arthroscopic full-thickness rotator cuff repair: single-row versus
dual-row fixation. Arthroscopy, 21(11): 1307-16, 2005. 31. Nyffeler, R. W.; Werner, C. M.; Sukthankar, A.; Schmid, M. R.; and Gerber, C.:
Association of a large lateral extension of the acromion with rotator cuff tears. J
16. Jost, B.; Zumstein, M.; Pfirrmann, C. A. W.; and Gerber, C.: Long Term Outcome Bone Joint Surg Am, 88(4): 800-5, 2006.
After Structural Failure of Rotator Cuff Repair. submitted, 2004.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
210 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 211

32. Sukthankar, A.; R. W. Nyffeler, R. W.; Werner, C. M. L.; Brucker, P.; and Gerber, C.: 46. Watson, M.: Major Ruptures of the Rotator Cuff. The Results of Surgical Repair in
Lateral extension of the acromion and rotator cuff tear. Submitted, 2006. 89 Patients. J Bone Joint Surg, 67-B: 618 --624, 1985.
33. Mallon, W. J.; Misamore, G.; Snead, D. S.; and Denton, P.: The impact of preop- 47. Dahners, L. E.; Gilbert, J. A.; Lester, G. E.; Taft, T. N.; and Payne, L. Z.: The effect
erative smoking habits on the results of rotator cuff repair. J Shoulder Elbow of a nonsteroidal antiinflammatory drug on the healing of ligaments. Am J
Surg, 13(2): 129-32, 2004. Sports Med, 16(6): 641-6, 1988.

SYMPOSIA SHOULDER/ELBOW
34. Weiner, D. S., and MacNab, I.: Superior Migration of the Humeral Head. A 48. Cohen, D. B.; Kawamura, S.; Ehteshami, J. R.; and Rodeo, S. A.: Indomethacin
Radiological Aid in the Diagnosis of Tears of the Rotator Cuff. J. Bone Joint Surg., and celecoxib impair rotator cuff tendon-to-bone healing. Am J Sports Med,
52-B:(3): 524-527, 1970. 34(3): 362-9, 2006.
35. Goutallier, D.; Postel, J.-M.; Bernageau, J.; Lavau, L.; and Voisin, M.-C.: Fatty 49. Meyer, D. C.; Jacob, H. A.; Nyffeler, R. W.; and Gerber, C.: In vivo tendon force
Muscle Degeneration in Cuff Ruptures. Clin.Orthop. Rel Res., 304(304): 78-83, measurement of 2-week duration in sheep. J Biomech, 37(1): 135-40, 2004.
1994. 50. Lewis, C. W.; Schlegel, T. F.; Hawkins, R. J.; James, S. P.; and Turner, A. S.: The
36. Uniform requirements for manuscripts submitted to biomedical journals. effect of immobilization on rotator cuff healing using modified Mason-Allen
International Committee of Medical Journal Editors. N Engl J Med, 336(4): 309- stitches: a biomechanical study in sheep. Biomed Sci Instrum, 37: 263-8, 2001.
15., 1997. 51. Thomopoulos, S.; Williams, G. R.; and Soslowsky, L. J.: Tendon to bone healing:
37. Gerber, C.; Schneeberger, A. G.; Beck, M.; and Schlegel, U.: Mechanical Strength differences in biomechanical, structural, and compositional properties due to a
of Repairs of The Rotator Cuff. J. Bone Joint Surg., 76-B: 371-380, 1994. range of activity levels. J Biomech Eng, 125(1): 106-13, 2003.
38. Kempf, J. F. et al.: Etude multicentrique de 210 ruptures de la coiffe des rotateurs 52. Takai, S.; Woo, S. L.; Horibe, S.; Tung, D. K.; and Gelberman, R. H.: The effects of
traitées par acromioplastie sous arthroscopie. frequency and duration of controlled passive mobilization on tendon healing. J
Acta Orthop Belg, 61(Suppl 1): 23-31., 1995. Orthop Res, 9(5): 705-13, 1991.

39. Uhthoff, H. K.; Sano, H.; Trudel, G.; and Ishii, H.: Early reactions after reimplan- 53. Wickstrom, J.: Birth Injuries of the Brachial Plexus. Treatment of Defects in the
tation of the tendon of supraspinatus into bone. A study in rabbits. J Bone Joint shoulder. Clin.Orthop.Rel.Res., 23: 187 --196, 1962.
Surg Br, 82(7): 1072-6., 2000. 54. Meyer, D. C.; Hoppeler, H.; von Rechenberg, B.; and Gerber, C.: A pathomechani-
40. Goodmurphy, C. W.; Osborn, J.; Akesson, E. J.; Johnson, S.; Stanescu, V.; and cal concept explains muscle loss and fatty muscular changes following surgical
Regan, W. D.: An immunocytochemical analysis of torn rotator cuff tendon taken tendon release. J Orthop Res, 22(5): 1004-7, 2004.
at the time of repair. J Shoulder Elbow Surg, 12(4): 368-74, 2003. 55. Zanetti, M.; Gerber, C.; and Hodler, J.: Quantitative Assessment of The Muscles of
41. Galatz, L. M.; Sandell, L. J.; Rothermich, S. Y.; Das, R.; Mastny, A.; Havlioglu, N.; the Rotator Cuff with Magnetic Resonance Imaging. Invest. Radiol., 33(3): 163-
Silva, M. J.; and Thomopoulos, S.: Characteristics of the rat supraspinatus tendon 170, 1998.
during tendon-to-bone healing after acute injury. J Orthop Res, 24(3): 541-50, 56. Safran, O.; Derwin, K. A.; Powell, K.; and Iannotti, J. P.: Changes in rotator cuff
2006. muscle volume, fat content, and passive mechanics after chronic detachment in a
42. St Pierre, P. P.; Olson, E. J.; Elliott, J. J.; O'Hair, K. C.; L.A., M.; and Ryan, J.: canine model. J Bone Joint Surg Am, 87(12): 2662-70, 2005.
Tendon - Healing to Cortical Bone Compared with Healing to a Cancelous 57. Nakagaki, K.; Ozaki, J.; Tomita, Y.; and Tamai, S.: Alterations in the supraspinatus
Trough. A Biomechanical and Histological Evaluation in Goats. J. Bone Joint muscle belly with rotator cuff tearing: Evaluation with magnetic resonance imag-
Surg., 77-A(12): 1858 - 1866, 1995. ing. J. Shoulder Elbow Surg., 3: 88-93, 1994.
43. Uhthoff, H. K., and Sarkar, K.: Surgical Repair of Rotator Cuff Ruptures. The 58. Crawford, G. N. C.: Some effects of tenotomy on adult striated muscle. J. Anat.,
Importance of The Subacromial Bursa. J. Bone Joint Surg., 73-B(3): 399-401, 123(2): 389-396, 1977.
1991. 59. Fabis, J.; Kordek, P.; Bogucki, A.; Synder, M.; and Kolczynska, H.: Function of the
44. Uhthoff, H. K.; Seki, M.; Backman, D. S.; Trudel, G.; Himori, K.; and Sano, H.: rabbit supraspinatus muscle after detachment of its tendon from the greater
Tensile strength of the supraspinatus after reimplantation into a bony trough: an tubercle. Observations up to 6 months. Acta Orthop Scand, 69(6): 570-4, 1998.
experimental study in rabbits. J Shoulder Elbow Surg, 11(5): 504-9, 2002. 60. Matano, T.; Tamai, K.; and Kurokawa, T.: Adaptation of skeletal muscle in limb
45. Uhthoff, H. K.; Trudel, G.; and Himori, K.: Relevance of pathology and basic lengthening: a light diffraction study on the sarcomere length in situ. J Orthop
research to the surgeon treating rotator cuff disease. J Orthop Sci, 8(3): 449-56, Res, 12(2): 193-6, 1994.
2003.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
211
SYM 07:Layout 1 1/12/07 11:40 AM Page 212

ARTHROSCOPIC ROTATOR CUFF REPAIR:

PROOF OF CONCEPT-DOUBLE ROW REPAIR
SYMPOSIA SHOULDER/ELBOW

Hiroyuki Sugaya, MD

Reported re-tear rate — Beach-chair position

• 20 to 90% in open / mini-open repairs — Subacrominal decompression
— Lower in smaller tears — Cuff evaluation
— Higher in larger tears — Cuff mobilization
— Better functional outcome in shoulders with better • Double-row repair using suture anchors
integrity — Shoulders with delamination
Arthroscopic Repair – More than 80% of rotator cuff tear has delamination
• Functional outcomes (Matsuki)
– Each layer repaired separately with simple sutures
— Comparable to open or mini-open
• Repair integrity (Sugaya)
— Single-row repair — Shoulders without delamination
– Lateral row repaired with simple sutures; Medial row
— 29% re-tear (Boileau)
repaired with mattress sutures
— 94% re-tear in large and massive tears (Galatz)
Postoperative schedule
Double-row Repair
— Immobilization: 3 to 4 weeks
• Superior to transosseous or single-row repair in
– Isometric cuff ex
— Initial fixation strength – Scapular & Trunk ex
— Footprint coverage — Passive ROM ex: 3 weeks
— Repair site stability during motion — Active ROM ex: 6 weeks
Single vs. Double-Row — Sports, labor: 6 months
• Retrospective comparative study (Sugaya)
Postoperative MRI (Sugaya)
— Functional outcome similar
— Type I: sufficient thickness with homogenously low
— Repair integrity by MRI intensity
Double-row＞Single-row — Type II: sufficient thickness with partial high intensity
Prospective Outcome Study — Type III: insufficient thickness without discontinuity
• 150 consecutive patients — Type IV: presence of a minor discontinuity
— Failed conservative treatment — Type V: presence of a major discontinuity
— Candidates for primary rotator cuff repair
Results
— Informed consent prior to surgery • Functional Outcome
• Inclusion criteria
— UCLA score
— Full-thickness tear
– Overall: 14.5→32.9（18-35）
— Arthroscopic double-row repair
— ASES score
— Postoperative MRI @ 1-2 years
– Overall: 42.3→94.3（60-100）
— Minimum 2 year follow-up • Repair Integrity
• 44 patients excluded
— Overall re-tear rate (types IV and V): 17.4%.
— 37 partial thickness tear – Small to medium tears: 5.4%
— 7 irreparable tears (Type IV: 1.8%, Type V: 3.6%)
• 106 enrolled – Large and massive tears: 40%
• 20 patients lost to follow-up (Type IV: 20%, Type V: 20%)
Subjects • Type V shoulders (large postoperative defect)
• 86 shoulders in 86 patients — Demonstrated significantly inferior functional outcome
— 52 males, 34 females (p<0.01)
— Mean age: 60.5 years (41-77) — Similar or even larger defect compared to pre-op tear size
— Mean F/U: 31.2 months (24-49) — Failed to reestablish rotator cuff function
— Post-op MRI: 13.4 months (12-24) • Type IV shoulders (small postoperative defect)
— Follow-up rate: 81% — Demonstrated no significant inferiority compared to the
• Preoperative tear size intact shoulders.
— 26 Small ( <1cm) — Smaller defect compared to pre-op tear size
— 30 Medium (1 to 3cm) — Rotator cuff function well reestablished
— 21 Large (3 to 5cm) To avoid creating type V shoulders
— 9 Massive (5cm< ) • Patient selection
Surgery — Residual muscle atrophy
— General anesthesia — Fatty degeneration

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
212 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 213

• Attention to delamination • Shoulders with large defects demonstrated significantly infe-

— Secure medial-row repair rior functional outcomes
— Increase initial fixation strength • Patient selection and management of delamination are
important factors to obtain satisfactory outcome
Conclusions

SYMPOSIA SHOULDER/ELBOW
• Arthroscopic double-row repair demonstrated improved
structural outcomes

REFERENCES 15. Lo IY, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing
1. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. the footprint of the rotator cuff. Arthroscopy. 2003;19:1035-1042.
Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon 16. Matsuki K, Sugaya H, Maeda K, Moriishi J. Delamination observed in full-thick-
really heal? J Bone Joint Surg Am. 2005;87:1229-40. ness rotator cuff tears. Presented at the AANA 24th annual meeting in Vancouver,
2. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique BC, Canada, 2005.
and preliminary results. Arthroscopy. 2002;18:454-63. 17. Meier SW, Meier JD, Levy AS, Parsons JR. Rotator cuff repair: the effect of double-
3. Calvert PT, Packer NP, Stoker DJ, Bayley JI, Kessel L. Arthrography of the shoulder row fixation versus single-row fixation on three-dimensional repair site.
after operative repair of the torn rotator cuff. J Bone Joint Surg Br. 1986;68:147- Presented at the AAOS 21st annual meeting in San Francisco, CA, 2004.
50. 18. Meier SW, Manigrasso MB. Rotator cuff repair: the effect of double-row fixation
4. Fealy S, Kingham TP, Altchek DW. Mini-open rotator cuff repair using a two-row on repair interface motion. Presented at the AAOS 22nd annual meeting in
fixation technique: outcomes analysis in patients with small, moderate, and large Washington, DC, USA and the AANA 24th annual meeting in Vancouver, BC,
rotator cuff tears. Arthroscopy. 2002; 18:665-70. Canada, 2005.

5. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and 19. Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to
repair integrity of completely arthroscopically repaired large and massive rotator large full-thickness rotator cuff tears: outcome at 2- to 6-year follow-up. J
cuff tears. J Bone Joint Surg Am. 2004;86:219-24. Shoulder Elbow Surg. 2002; 11:19-24.

6. Gartsman GM, Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of 20. Sano H, Wakabayashi I, Itoi E. Stress distribution in the supraspinatus tendon
full-thickness tears of the rotator cuff. J Bone Joint Surg. 1998; 80-A: 832-840. with partial-thickness tears: an analysis using two-dimensional finite element
model. J Shoulder Elbow Surg. 2006;15:100-5.
7. Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after
rotator cuff repair. Clin Orthop. 1994;304:43-53. 21. Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome
after arthroscopic full-thickness rotator cuff repair: single-row versus dual-row fix-
8. Gerber C, Fuchs B, Holder J. The results of repair of massive tears of the rotator ation. Arthroscopy. 2005;21:1307-16.
cuff. J Bone Joint Surg Am. 2000;82:505-15.
22. Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rota-
9. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degenera- tor cuff repair results by magnetic resonance imaging. Clin Orthop.
tion in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop 1997;344:275-83.
Relat Res. 1994 Jul;(304):78-83.
23. Tuoheti Y, Itoi E, Yamamoto N, Seki N, Abe H, Minagawa H, Okada K, Shimada
10. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA Y. Contact area, contact pressure, and pressure patterns of the tendon-bone inter-
3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of face after rotator cuff repair. Am J Sports Med. 2005;33:1869-74.
the cuff. J Bone Joint Surg Am. 1991;73:982-9.
24. Wakabayashi I, Itoi E, Sano H, Shibuya Y, Sashi R, Minagawa H, Kobayashi M.
11. Jones CK, Savoie FH 3rd. Arthroscopic repair of large and massive rotator cuff Mechanical environment of the supraspinatus tendon: a two-dimensional finite
tears. Arthroscopy. 2003;19:564-71. element model analysis. J Shoulder Elbow Surg. 2003;12:612-7.
12. Jost B, Pfirrmann CW, Gerber C, Switzerland Z. Clinical outcome after structural 25. Waltrip RL, Zheng N, Dugas JR, Andrews JR. Rotator cuff repair: a biomechanical
failure of rotator cuff repairs. J Bone Joint Surg Am. 2000;82:304-14. comparison of three techniques. Am J Sports Med. 2003; 31:493-497.
13. Knudsen HB, Gelineck J, Sojbjerg JO, Olsen BO. Functional and magnetic reso- 26. Wilson F, Hinov V, Adams G. Arthroscopic repair of full-thickness tears of the
nance imaging evaluation after single-tendon rotator cuff reconstruction. J shoul- rotator cuff: 2- to 14-year follow-up. Arthroscopy. 2002; 18:136-144.
der Elbow Surg. 1999;8:242-6.
27. Worland RL, Arredondo J, Angles F, Lopez-Jimenez F. Repair of massive rotator
14. Liu SH, Baker CL. Arthroscopically assisted rotator cuff repair: correlation of cuff tears in patients older than 70 years. J shoulder Elbow Surg. 1999;8:26-30.
functional results with integrity of the cuff. Arthroscopy. 1994;10:54-60.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
213
SYM 07:Layout 1 1/12/07 11:40 AM Page 214

ARTHROSCOPIC SUB SCAPULARIS REPAIR

Laurent LaFosse, MD
SYMPOSIA SHOULDER/ELBOW

1 ANATOMY – Biceps
• Big muscle • Ant pulley = sling by SGHL and CHL
– All scapula Ant surface • +/- Involved with tendon tear
– 50% RC strength • Subluxation => dislocation
• 2 parts attachment – Supra Spinatus
– Sup 2/3 : tendon • Separately
– Inf 1/3 : muscle • Or still attached together
2 ANATOMY 8 EVALUATION
• Intra-articular side ⇔ Post & Sup • Own Symptoms & Natural History
– Superior 1/3 arthroscopic visualization only • Exam :
– Long sliding distance (3cm) ⇔ rotation – Lift of
– Relation biceps Anterior pulley ⇔ Ant Stability – Belly press test
– Inf 2/3 covererd by capsule – Bear hug
• Extra-articular side ⇔Ant & Sup 9 ARTHROSCOPIC VISUALIZATION
– Sup 1/3 behind coracoid • Posterior Portal => GH Joint
– Muscle crossed by plexus & axillar artery • Related to the positionnimg
– Inf 2/3 crossed by axillaris nerve • Lateral decubitus
3 ANATOMY • Beach chair in neutral position
• Insertion : Foot Print • Beach chair + traction => flexion
– Leaser tuberosity • Limited access
– Long & wide (3 x 2 cm) • Sup 1/3
• Articular side
– Ant border biceps groove ⇔ Biceps stability
• Lat attachment if LBH Ant Grove open
• Inervation
• Easier when LHB torn or TenodeseD
– Different than post sup cuff
• Ant subscap =>open rot int, 70 scope
– From ant plexus
– Multiples roots 10 ARTHROSCOPIC VISUALIZATION
• Lat Portal
4 ANATOMY
• GH Joint through Rot Int or SSP tear\
• SUB SCAP # SUP POST CUFF
• On line with sup border
• SHOULDER ⇔ KNEE • Sup 1/3 of Ant tendon & muscle
HUMERAL HEAD ⇔ FEMORAL CONDYLE • Ant Sup Portal
– Supra + Infra spinatus ⇔ ACL • ⇔ delto pectoral open surgery
– Subscapularis ⇔ PCL • Access under coracoid & conjoint tendon
– Sup post cuff ⇔ post sup active sling • Access to
– Subscap ⇔ ant active sling behind coracoid • Muscle
• Subscap Nerves
5 PATHOLOGY
• Plexus & Axillar Artery
• Degenerative or traumatic
• Axillaris nerve
• Location of the tear :
– Vertical : 11 RELEASE
• Partial Sup 1/3 • ⇔ Location tear
• Sup 1/3 retracted • Post : deep layer / GHL
• Retraction Extended to Inf 2/3 • Sup : under coracoid
– AP : • Ant : plexus, Axillary nerve
• Deep layer only • ⇔ Retraction
• Total thickness • Partial => GH surgery
• Mecanism • Massive => GH & Ant access
– Sup => inf
– Deep layer => Superficial layer 12 REDUCTION
• Grasper
6 PATHOLOGY • Sutures through small elective portal
• Consequences of Active Ant Sup wall weakness
– Ant sup migration 13 FIXATION
– Coracoid impingement • Portals
• Muscle atrophy & FattyDegeneration • Ant sup & Ant Inf , lateral / conjoint tendon
– Grade 1 => 4 • No Canula
– Irreversible • Adaptable / tear
• Anchors placement
7 PATHOLOGY • Sup 1/3 : close GHL & CHL
• Association • Deep layer :

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
214 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 215

• Inf anchor first • No passive ER & active IR before 3 M

• Difficult access
18 CLASSIFICATION
• Massive : Foot Print Fixation W (Cassiopea)
• LHB
• 2 anchors
– A : Normal
• 5 fixation spots

SYMPOSIA SHOULDER/ELBOW
– B : Subluxated
14 ASSOCIATED TREATMENT – C : Dislocated
• Coracoidoplasty
19 CLASSIFICATION
• LBH tenodesis
• Type I : Partial Sup 1/3
• SSP & ISP
• Type II : Retracted Sup 1/3
– After Sub Scap
• Type III: Retracted tear sup 2/3
– Except when SSP & Sub Scap attached
• Type IV: Extended lesion but head still centered,
15 LEASER TUBEROSITY FRACTURE • Type V: ant sup Migration Retracted tear, bad tendon or
• Traumatic Fatty degeneration = 3 or 4
• Symptoms +++ • “F” when Association with Fracture LT
• Sub Scap => medio inf retraction +++
20 INDICATIONS => SUB SCAP
• Fixation with anchors & suture > screw
• Type I, II, III => ARTHRO REPAIR
16 PROBLEMS Good results expected
• Extensive tear => more portals • Type IV => ARTHRO REPAIR
• Release => Bleeding • Good result for pain and function, No strength, passive
• Swelling => neck and chest Humeral Head centering
• Long • Type V => TENDON TRANSFERT +/- CORACOPLASTY
17 POST OP CARE 21 INDICATIONS => LHB
• Isolated or if > Post sup tear => sling IR • Type A => None or resection if lesion
• Massive Post Sup & Ant tear => small abd pillow • Type B & C => Tenotomy or Tenodesis
• Immobilization 6 W

REFERENCES 7. Gerber C, Jost B. Les ruptures isolées du subscapularis : tiers supérieur et com-
1. Burkhart SS, Tehrany AM. Arthroscopic Subscapularis Tendon Repair : Technique plètes. In Augereau B, Gazielly D. Les ruptures transfixiantes de la coiffe des rota-

; 85, Suppl ΙΙ : 117-118.

and Preliminary Results. The Journal of Arthroscopic and Related Surgery, 2002 ; teurs subscapularis inclus. Symposium de la S.O.F.C.O.T. Rev Chir Orthop, 1999
18 (5): 454-463.
2. Burkhart SS, Lo IKY. Current Concept In Arthroscopic Rotator Cuff Repair. Am J 8. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty degeneration in
Sports Med, 2003, 31: 308-324. cuff ruptures : Pre and post-operative evaluation by C.T. scan. Clin Orthop, 1994
; 304 : 78-83.
3. Constant C. Assessment of the shoulder. In WATSON M. ed. Surgical disorders of
the shoulder. Edinburgh: Churchill Livingstone, 1991. 9. Hauser ED. Avulsion of the tendon of the subscapularis muscle. J Bone Joint
Surg [Am ], 1954 ; 36 : 139-141.
4. Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF. Traumatic Tears of the
Subscapularis Tendon. Clinical Diagnosis, Magnetic Resonance Imaging 10. Lo IKY, FRCSC, Burkhart SS. Current Concepts in Arthroscopic Rotator Cuff
Findings, and Operative Treatment. Am J Sports Med, 1997; 25: 13-22. Repair. Am J Sports Med, 2003; 31 : 308-324.

5. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. 11. Nove-Josserand L, Levigne CH, Noël E, Walch G. Les lésions isolées du sous
Clinical features in 16 cases. J Bone Joint Surg [Br], 1991 ; 73 : 389-394. scapulaire : A propos de 21 cas. Rev Chir Ortho, 1994 ; 80 : 595-601.

6. Gerber C, Hersche O, Farron A. Isolated Rupture of the Subscapularis Tendon. 12. Patte D. The subcoracoid impingement. Clin Orthop, 1990 ; 254 : 54-59.
Results of operative repair. J Bone Joint Surg [Am], 1996 ; 78A: 1015-1023. 13. Wright JM, Heavrin B, Hawkins RJ, F.R.C.S.C., Noonan T. Arthroscopic
Visualization of the Subscapularis Tendon. The Journal of Arthroscopic and
Related Surgery, 2001 ; 17 (7): 677-684.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
215
SYM 07:Layout 1 1/12/07 11:40 AM Page 216

MANAGEMENT OF MASSIVE “IRREPARABLE”

ROTATOR CUFF TEARS
SYMPOSIA SHOULDER/ELBOW

Jon J.P. Warner, MD

I. Definitions: The “unreparable” rotator cuff tear is like… g. Sutures Used

…the unrunnable marathon h. Postoperative Compliance
…the unchuggable beer
VII. Surgical Options:
…the unreturnable tennis serve
a. Arthroscopic Debridement/Biceps Tenotomy:
…the unskiable slope
• Durability is a Question
“Massive” ≠ “Irreparable”
• Suited to Elderly, Frail Patients
• North American Definition (Cofield): > 5 cm diameter
• French Experience is Good
• European Definition (Gerber): > 2 tendons torn after
b. Arthroscopic Partial Tendon Repair:
debridement
• Scientific Evidence Supports Role
II. Forgotten Factors: • Indicated in Cases of Flexible Shoulder with Marked
a. Quality of Tendon Tissue ER Weakness and Positive EMG (see below)
b. Muscle Quality/Quantity: Fatty Replacement/Atrophy c. Tendon Transfer: Latissimus Dorsi for Posterosuperior
c. Quality of Bone (Greater Tuberosity Osteopenia) tears & Pectoralis Major for Anterosuperior Tear:
d. Neurogenic Cause of Pain/Weakness (see below) • For Mild/Moderate Weakness with Pain
e. Surgeon Skill • With Intact Deltoid
• Intact Subscapularis (for Latissimus Transfer)
III. Relevant Clinical/Biological/Biomechanical Factors:
• No Stiffness
a. Atrophy is Reversible/Fatty Replacement of Muscles is
• Motivated Patient
Irreversible
• No Arthritis
b. Poor Bone Quality Occasionally Precludes Anchor
d. Hemiarthroplasty:
Placement
• Pain
c. Tendons Which Tear are Never Normal
• Moderate Weakness
d. Tendon Delamination is Typical and Relevant to Repair
• Contained Humeral Head
e. Tendon Quality and Muscle Quality are Probably the
• Arthritis and Massive RCT with Intact Subscapularis
Weakest Link…Sutures are Strong and Anchor Fixation is
e. Reverse/Inverse Shoulder Prosthesis:
Usually Strong.
• Pseudoparalysis with/without Pain
f. Chronic Smoking is a Very Negative Prognostic Factor for
• Absent Subscapularis with antero-superior subluxa-
Tendon Healing
tion of humeral head
IV. Irreparable Massive Tendon Tear is a Spectrum of Clinical • Best Results with Intact Teres Minor
Presentations: • If Teres minor is Deficient may Perform Concomitant
a. Good Function/Strength with Minimal/No Pain Tendon Transfer (Boileau)
b. Good Function/Strength with Pain • Static Superior Subluxation of Humeral Head
c. Weakness with/without Pain
VIII. Evidence for Suprascapular Nerve (SSN) Cause of
d. Pseudoparalysis without Pain
Pain/Weakness in Some Cases
e. Pseudoparalysis with Pain
• SSN Entrapment and Dysfunction is Recognized as a
f. Failed Prior Surgery with Associated Pathology Such as
Rare Condition Described as an Isolated Pathology
Deltoid Injuries
• Nerve Entrapment is Usually Due to a Mass or Traction
g. Tear Configuration = Anterosuperior (Supraspinatus +
at the Suprascapular Notch
Infraspinatus)
• SSN can also be Associated with RCT
h. Tear configuration = Posterosuperior (Supraspinatus +
• RCT can cause SSN Injury: Traction on Nerve at
Subscapularis)
Suprascapular Notch from Tendon Retraction
i. Worker’s Compensation Etiology
j. Flexible or Stiff Shoulder
V. The Diagnosis Can be Made Before Surgery is Performed:
…a Tendon Tear is Irreparable if there is…
a. Static Superior Subluxation of the Humeral Head with
an Acromiohumeral Interval < 5mm
b. Marked External Rotation Weakness with a Lag Sign
c. Fatty Muscle Replacement > Stage 3 on MRI (more
Muscle than Fat in Fossa)
VI. Why do Tendon Repairs Fail?
a. Tendon Quality
b. Bone Quality • Hypothesis (Warner): Traction Occurs Around the Base
c. Muscle Quality of the Spine of the Scapula as a Consequence of
d. Repair Technique/Surgeon Skill and Judgment Infraspinatus Retraction. (Bamania) Traction may occur
e. Neurologic Factors (see below) at transverse scapular notch. This is why Arthroscopic
f. Implant Used
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
216 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 217

Partial Repair, Described by Burkhart, may Work.

IX. SSN Pathology and Massive RCT (Clinical Experience)
• 13 Months: 216 Patients Diagnosed with RCT Requiring
Surgery

SYMPOSIA SHOULDER/ELBOW
• 26 cases with Massive RCT + Fatty Replacement > Stage 2
• EMG Analysis
— 7/26 (27%) with + SSN Dysfunction
• 6/7 with SSN Injury Underwent Surgery
— 3 Arthroscopic Partial Posterior Cuff Repairs
— 1 Arthroscopic Complete RTC Repair
— 1 Latissimus Dorsi Transfer
— 1 Arthroscopic Debridement
• 4/4 Patients with Partial or Complete RTC Repair had
Improved EMG Function of SSN and Clinical
Improvement of Pain and Function
X. SSN Decompression
• Traditionally done open
• Recently arthroscopic techniques have been described
(Lafosse)

REFERENCES 16. Iannotti, J. P.; Hennigan, S.; Herzog, R.; Kella, S.; Kelley, M.; Leggin, B.; and
Massive Rotator Cuff Tears Williams, G. R.: Latissimus dorsi tendon transfer for irreparable posterosuperior
rotator cuff tears. Factors affecting outcome. J Bone Joint Surg Am, 88(2): 342-8,
1. Burkhart, S. S.: Reconciling the paradox of rotator cuff repair versus debridement: 2006.
a unified biomechanical rationale for the treatment of rotator cuff tears.
Arthroscopy, 10(1): 4-19, 1994. 17. Jost, B.; Puskas, G. J.; Lustenberger, A.; and Gerber, C.: Outcome of pectoralis
major transfer for the treatment of irreparable subscapularis tears. J Bone Joint
2. Burkhart, S. S.; Nottage, W. M.; Ogilvie-Harris, D. J.; Kohn, H. S.; and Pachelli, A.: Surg Am, 85-A(10): 1944-51, 2003.
Partial repair of irreparable rotator cuff tears. Arthroscopy, 10(4): 363-70, 1994.
18. Miniaci, A., and MacLeod, M.: Transfer of the latissimus dorsi muscle after failed
3. Cofield, R. H.: Rotator cuff disease of the shoulder. J Bone Joint Surg Am, 67(6): repair of a massive tear of the rotator cuff. A two to five-year review. J Bone Joint
974-9, 1985. Surg Am, 81(8): 1120-7, 1999.
4. Gartsman, G. M.: Massive, irreparable tears of the rotator cuff. Results of opera- 19. Pearle, A. D.; Kelly, B. T.; Voos, J. E.; Chehab, E. L.; and Warren, R. F.: Surgical
tive debridement and subacromial decompression. J Bone Joint Surg Am, 79(5): technique and anatomic study of latissimus dorsi and teres major transfers. J
715-21, 1997. Bone Joint Surg Am, 88(7): 1524-31, 2006.
5. Gerber, C.; Fuchs, B.; and Hodler, J.: The results of repair of massive tears of the 20. Resch, H.; Povacz, P.; Ritter, E.; and Matschi, W.: Transfer of the pectoralis major
rotator cuff. J Bone Joint Surg Am, 82(4): 505-15, 2000. muscle for the treatment of irreparable rupture of the subscapularis tendon. J
6. Goutallier, D.; Postel, J. M.; Bernageau, J.; Lavau, L.; and Voisin, M. C.: Fatty mus- Bone Joint Surg Am, 82(3): 372-82, 2000.
cle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. 21. Warner, J. J.: Management of massive irreparable rotator cuff tears: the role of
Clin Orthop Relat Res, (304): 78-83, 1994. tendon transfer. Instr Course Lect, 50: 63-71, 2001.
7. Rockwood, C. A., Jr.; Williams, G. R., Jr.; and Burkhead, W. Z., Jr.: Debridement of 22. Warner, J. J., and Parsons, I. M. t.: Latissimus dorsi tendon transfer: a comparative
degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am, 77(6): analysis of primary and salvage reconstruction of massive, irreparable rotator cuff
857-66, 1995. tears. J Shoulder Elbow Surg, 10(6): 514-21, 2001.
8. Rokito, A. S.; Cuomo, F.; Gallagher, M. A.; and Zuckerman, J. D.: Long-term func- Hemiarthroplasty
tional outcome of repair of large and massive chronic tears of the rotator cuff. J
Bone Joint Surg Am, 81(7): 991-7, 1999. 23. Field, L. D.; Dines, D. M.; Zabinski, S. J.; and Warren, R. F.: Hemiarthroplasty of
the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg, 6(1): 18-23,
9. Sugihara, T.; Nakagawa, T.; Tsuchiya, M.; and Ishizuki, M.: Prediction of primary 1997.
reparability of massive tears of the rotator cuff on preoperative magnetic reso-
nance imaging. J Shoulder Elbow Surg, 12(3): 222-5, 2003. 24. Sanchez-Sotelo, J.; Cofield, R. H.; and Rowland, C. M.: Shoulder hemiarthroplas-
ty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone
10. Tingart, M. J.; Apreleva, M.; Zurakowski, D.; and Warner, J. J.: Pullout strength of Joint Surg Am, 83-A(12): 1814-22, 2001.
suture anchors used in rotator cuff repair. J Bone Joint Surg Am, 85-A(11): 2190-
8, 2003. 25. Williams, G. R., Jr., and Rockwood, C. A., Jr.: Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg, 5(5): 362-7, 1996.
11. Walch, G.; Edwards, T. B.; Boulahia, A.; Nove-Josserand, L.; Neyton, L.; and
Szabo, I.: Arthroscopic tenotomy of the long head of the biceps in the treatment 26. Zuckerman, J. D.; Scott, A. J.; and Gallagher, M. A.: Hemiarthroplasty for cuff tear
of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder arthropathy. J Shoulder Elbow Surg, 9(3): 169-72, 2000.
Elbow Surg, 14(3): 238-46, 2005. Reverse Shoulder Arthroplasty
Tendon Transfers 27. Boileau, P.; Chuinard, C.; and Trojani, C.: Modified Latissimus Dorsi and Teres
12. Aoki, M.; Okamura, K.; Fukushima, S.; Takahashi, T.; and Ogino, T.: Transfer of Major Transfer for External Rotation Deficit of the Shoulder. Nice Shoulder
latissimus dorsi for irreparable rotator-cuff tears. J Bone Joint Surg Br, 78(5): 761- Course, 2006.
6, 1996. 28. Boileau, P.; Watkinson, D.; Hatzidakis, A. M.; and Hovorka, I.: Neer Award 2005:
13. Galatz, L. M.; Connor, P. M.; Calfee, R. P.; Hsu, J. C.; and Yamaguchi, K.: The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture
Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff sequelae, and revision arthroplasty. J Shoulder Elbow Surg, 15(5): 527-40, 2006.
insufficiency. J Shoulder Elbow Surg, 12(1): 1-5, 2003. 29. Boileau, P.; Watkinson, D. J.; Hatzidakis, A. M.; and Balg, F.: Grammont reverse
14. Gerber, C.: Latissimus dorsi transfer for the treatment of irreparable tears of the prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg, 14(1
rotator cuff. Clin Orthop Relat Res, (275): 152-60, 1992. Suppl S): 147S-161S, 2005.

15. Gerber, C.; Vinh, T. S.; Hertel, R.; and Hess, C. W.: Latissimus dorsi transfer for 30. Frankle, M.; Siegal, S.; Pupello, D.; Saleem, A.; Mighell, M.; and Vasey, M.: The
the treatment of massive tears of the rotator cuff. A preliminary report. Clin Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe
Orthop Relat Res, (232): 51-61, 1988. rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J
Bone Joint Surg Am, 87(8): 1697-705, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
217
SYM 07:Layout 1 1/12/07 11:40 AM Page 218

31. Guery, J.; Favard, L.; Sirveaux, F.; Oudet, D.; Mole, D.; and Walch, G.: Reverse 37. Drez, D., Jr.: Suprascapular neuropathy in the differential diagnosis of rotator
total shoulder arthroplasty. Survivorship analysis of eighty replacements followed cuff injuries. Am J Sports Med, 4(2): 43-5, 1976.
for five to ten years. J Bone Joint Surg Am, 88(8): 1742-7, 2006. 38. Fabre, T.; Piton, C.; Leclouerec, G.; Gervais-Delion, F.; and Durandeau, A.:
32. Sirveaux, F.; Favard, L.; Oudet, D.; Huquet, D.; Walch, G.; and Mole, D.: Entrapment of the suprascapular nerve. J Bone Joint Surg Br, 81(3): 414-9, 1999.
Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral 39. Kaplan, P. E., and Kernahan, W. T., Jr.: Rotator cuff rupture: management with
SYMPOSIA SHOULDER/ELBOW

osteoarthritis with massive rupture of the cuff. Results of a multicentre study of suprascapular neuropathy. Arch Phys Med Rehabil, 65(5): 273-5, 1984.
80 shoulders. J Bone Joint Surg Br, 86(3): 388-95, 2004.
40. Mallon, W. J.; Wilson, R. J.; and Basamania, C. J.: The association of suprascapu-
33. Werner, C. M.; Steinmann, P. A.; Gilbart, M.; and Gerber, C.: Treatment of painful lar neuropathy with massive rotator cuff tears: a preliminary report. J Shoulder
pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III Elbow Surg, 15(4): 395-8, 2006.
reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am, 87(7):
1476-86, 2005. 41. Martin, S. D.; Warren, R. F.; Martin, T. L.; Kennedy, K.; O'Brien, S. J.; and
Wickiewicz, T. L.: Suprascapular neuropathy. Results of non-operative treatment. J
Suprascapular Neuropathy Bone Joint Surg Am, 79(8): 1159-65, 1997.
34. Albritton, M. J.; Graham, R. D.; Richards, R. S., 2nd; and Basamania, C. J.: An 42. Vad, V. B.; Southern, D.; Warren, R. F.; Altchek, D. W.; and Dines, D.: Prevalence
anatomic study of the effects on the suprascapular nerve due to retraction of the of peripheral neurologic injuries in rotator cuff tears with atrophy. J Shoulder
supraspinatus muscle after a rotator cuff tear. J Shoulder Elbow Surg, 12(5): 497- Elbow Surg, 12(4): 333-6, 2003.
500, 2003.
43. Warner, J. P.; Krushell, R. J.; Masquelet, A.; and Gerber, C.: Anatomy and relation-
35. Antoniou, J.; Tae, S. K.; Williams, G. R.; Bird, S.; Ramsey, M. L.; and Iannotti, J. P.: ships of the suprascapular nerve: anatomical constraints to mobilization of the
Suprascapular neuropathy. Variability in the diagnosis, treatment, and outcome. supraspinatus and infraspinatus muscles in the management of massive rotator-
Clin Orthop Relat Res, (386): 131-8, 2001. cuff tears. J Bone Joint Surg Am, 74(1): 36-45, 1992.
36. Brown, T. D.; Newton, P. M.; Steinmann, S. P.; Levine, W. N.; and Bigliani, L. U.: 44. Zanotti, R. M.; Carpenter, J. E.; Blasier, R. B.; Greenfield, M. L.; Adler, R. S.; and
Rotator cuff tears and associated nerve injuries. Orthopedics, 23(4): 329-32, Bromberg, M. B.: The low incidence of suprascapular nerve injury after primary
2000. repair of massive rotator cuff tears. J Shoulder Elbow Surg, 6(3): 258-64, 1997.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
218 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 219

SYMPOSIA SHOULDER/ELBOW
CONTROVERSIES IN THE MANAGEMENT OF
PROXIMAL HUMERUS FRACTURES (M)
Moderator: Frances Cuomo, MD

Optimum treatment modalities for the challenging proximal humerus fracture remains a
difficult and complex problem for the orthopaedic surgeon. This symposium will review the
controversies presented by these injuries and the most current techniques available to
maximize results and minimize complications.

I. Percutaneous Fixation of Proximal Humerus Fractures: Timing and Technique

Evan L. Flatow, MD, New York, NY (a, c – Zimmer)

II. Open Reduction and Internal Fixation: New Techniques and Rationale
Ralph Hertel, MD, Bern, Switzerland (b – Synthes)

III. Question/Answer Session

Frances Cuomo, MD, New York, NY (n)

IV. Complications of Open Reducution and Internal Fixation: Can we Avoid Them?
Frances Cuomo, MD, New York, NY (n)

V. The Role of Traditional Humeral Head Replacement vs. the Reverse Prothesis in the
Treatment of Proximal Humerus Fractures.
Gregory P. Nicholson, MD, Chicago, IL (a, d, e – Zimmer, a – EBI, c – Innomed)

VI. Question/Answer Session

Frances Cuomo, MD, New York, NY (n)

V. Case Presentation/Debate
Frances Cuomo, MD, New York, NY (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
219
SYM 07:Layout 1 1/12/07 11:40 AM Page 220

PERCUTANEOUS FIXATION OF PROXIMAL HUMERUS

FRACTURES: TIMING AND TECHNIQUE
SYMPOSIA SHOULDER/ELBOW

Evan L. Flatow, MD

1. PHILOSOPHY
A. Old technique for SN Fx’s
B. New idea for complex Fx’s
C. Ideal for some cases
— skin problems
— prior humeral shaft surgery
— sick patients
D. Be prepared to “bail out”
E. Don’t pick your technique by easiest cases
— anything works for simple SN Fx’s!
2. INDICATIONS
A. Reducible but unstable SN Fx’s
— ideal indication
B. Some isolated GT Fx’s
— but tricky and ORIF reliable
C. Some 3-part Fx’s
— hardest case as rotation difficult to correct
D. Valgus Impacted 4-part Fx’s
\
— ideal indication

Keys:
E. NOT IDEAL: head splits, true dislocated 4-part Fx’s • Place elevator on anterolateral head, hit up and slightly
back (retroversion)
• Terminally threaded 2.5 to 3mm pins
• May start with power but finish by hand
• Remember head retroversion when placing pins
• Always check in two planes
• Early on, enlarge portal for finger to check pin entrance
• Never just backup a screw that perforates –place in a new
track
• Push skin down, cut pin, and pull skin over
• When swelling goes down pins will “point”
3. TIMING Aftercare:
A. Ideal first few days • GT pins out 2-3 weeks, SN pins out 4-5 weeks, but varies…
B. Possible up to 2 weeks (but hard) • Hand/elbow immediately
4. TECHNIQUE • Pendulum immediately if GT screws, otherwise after GT
1. Techniques developed by Benerschke, Jakob, Resch pins out
2. Careful image control • Assistive ROM after SN pins out
3. Elevate head
4. Pin SN
5. Reduce GT with hook
6. Pin or cannulated screw GT
7. Reduce LT (prn) with hook
8. Pin or cannulated screw LT prn

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
220 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 221

OPEN REDUCTION AND INTERNAL FIXATION: NEW TECHNIQUES

AND RATIONALE

SYMPOSIA SHOULDER/ELBOW
Ralph Hertel, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
221
SYM 07:Layout 1 1/12/07 11:40 AM Page 222

COMPLICATIONS OF OPEN REDUCTION INTERNAL FIXATION OF

PROXIMAL HUMERUS FRACTURES: CAN WE AVOID THEM?
SYMPOSIA SHOULDER/ELBOW

Frances Cuomo, MD

I. Introduction 2. Symptoms
A. Complications of Open Reduction and Internal Fixation- a. Pain, crepitus
Causes b. Loss of ROM
1. Errors in diagnosis/indications D. Post-Traumatic Arthritis
2. Errors in techniques 1. Causes
3. Improper aftercare a. Disrupted vascularity
B. Errors in Diagnosis/Indications b. Articular surface damage
1. Misdiagnosis c. Fixation penetration
a. Fracture type 2. Symptoms
2. Failure to diagnose a. Pain, loss of motion, crepitus
a. Associated injuries E. Prevention
b. Neurovascular injury 1. Stiffness
c. Charcot shoulder a. Early passive ROM
3. Indications b. Anatomic reduction
a. Poor rehab candidate 2. Malunion
C. Errors in Technique a. Anatomic reduction
1. Extensive soft tissue damage from approach b. Rigid fixation
2. Inadequate reduction c. Adequate exposure, radiographic imaging
3. Poor fixation 3. Nonunion
4. Joint penetration a. Rigid fixation
D. Improper Aftercare b. Bone graft PRN
1. Too early → nonunion, malunion c. Avoid aggressive PROM/AROM
a. Loss of fixation 4. AVN
2. Too late → stiffness a. Minimal ST stripping, minimal osteosynthesis
5. Arthritis
II. Complications
a. Avoid joint penetration, anatomic reduction vs. HHR
A. Types
6. Infections
1. Stiffness
a. Meticulous technique, minimal soft tissue stripping
2. Malunion
3. Nonunion III. Treatment
4. AVN A. General options
5. Post-traumatic arthritis 1. Prevention
6. Infection 2. Restore anatomy
7. Joint penetration 3. Release scar
8. Breakage 4. Reconstruct cuff/tuberosities
9. SA impingement 5. Arthroplasty for articular loss
10. N/V injury B. Specific Treatment
11.Heterotopic bone 1. Stiffness
B. Nonunion a. Dependent upon underlying cause
1. Causes b. Periarticular fibrosis → soft tissue release
a. Soft tissue interposition c. Malunion → osteotomy
b. Inadequate fixation 2. Malunion
c. Overly- aggressive PROM a. Intact joint → osteotomy/ORIF
d. Early AROM b. Articular involvement → HHR vs. TSR
2. Symptoms 3. Nonunion
a. Pain a. Intact articular surface → ORIF with bone graft
b. Weakness b. Articular involvement → HHR
c. Loss of AROM 4. AVN
C. AVN a. Replacement surgery
1. Causes b. Correction of malunion
a. ↑ injury severity 5. Post- Traumatic Arthritis
b. 4-part fractures a. HHR vs. TSR with osteotomy PRN
c. Soft tissue stripping

REFERENCES 3. Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high

1. Hernigou P, Germany W. Unrecognized shoulder joint penetration during fixa- complication rate following internal fixation of unstable proximal humerus frac-
tion of proximal fractures of the humerus. Acta Orthop Scand. April 2002; 73 tures with an angled blade plate. J Orthop Trauma. April 2006; 20 (4): 253-60.
(2): 140-3. 4. Smith AM, Sperling JW, Cofield RH. Complications of operative fixation of prox-
2. Hertel R, Hempfring A, Stiehler M, Leunig M. Predictors of humeral head imal humeral fractures in patients with rheumatoid arthritis. J Shoulder Elbow
ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. Nov-Dec 2005; 14 (6): 559-64.
Surg. Jul-Aug 2004; 13 (4): 427- 33. 5. Wirth MA. Late sequelae of proximal humerus fractures. Instr Course Lect. 2003;
52: 13-6 Review.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
222 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 223

THE ROLE OF TRADITIONAL HUMERAL HEAD REPLACEMENT

VS. THE REVERSE PROSTHESIS IN THE TREATMENT OF

SYMPOSIA SHOULDER/ELBOW
PROXIMAL HUMERUS FRACTURES
Gregory P. Nicholson, MD

ACUTE PROXIMAL HUMERUS FRACTURE — Hold PT

What Fractures Require Implant Arthroplasty? Have 2nd Generation Fracture Specific Implants Improved
• Displaced 4 Part Outcomes?
— (Not valgus impacted) • New geometry to allow tuberosity positioning
• Head split • Material to enhance bone healing to prosthesis
• Some 3 part fractures with comminution and osteopenia — Trabecular Metal
• Locked posterior dislocation with >40% head impaction — HA coating
• ? Chronic anterior dislocations — Reduced lateral metal and open neck of implant
• Guides and jigs to reproduce anatomy and to replicate trial
Hemiarthroplasty for Fractures
and definitive component position
• Hemiarthroplasty is “entry level” arthroplasty for most sur-
geons Early evidence that prosthetic position, tuberosity position,
• Difficult Arthroplasty tuberosity healing is improved.
— Arthroplasty itself and altered traumatized anatomy
Reverse Prosthesis for Acute Proximal Humerus Fractures
Keys to Success • Very little long term data
• Proper implant height and retroversion • Very little short term data
• Proper prosthetic head size
• Mobilization of tuberosities with sutures around boney • If a hemiarthroplasty in a fracture environment is difficult—
segements A reverse is even more difficult—
• Secure tuberostiy fixation in proper location: Rotation and Not from exposure, but from obtaining myofascial sleeve
height tension, and thus stability.
• Rotator cuff (interval) repair — Acute change in limb status. No prior fixed humeral
• Aftercare to avoid tuberosity displacement head elevation
Results of Hemiarthroplasty with Tuberosity Reconstruction Other issues:
for Fracture • Most current designs:
• Active elevation: Avg 80-120 degrees — Large proximal geometry with no ability to adequately
• Active ER: Avg. 20-50 degrees fixate tuberosities.
• Active IR Avg. variable — No ingrowth or even ongrowth ability. Tuberosities
• Pain relief: “Good to excellent” “pushed” away.
— Loss of teres minor – poor function
However: there seem to be no average results.
— Glenoid side is not injured and now need to implant
• Bimodal distribution:
component
— Pretty Good: AFE above 120 and satisfied
— Same complication rate for the reverse for CTA still exists
— Pretty Bad: AFE less than 60, ER less than 10, poor func-
(10-30%)
tion for ADL
Reverse for Acute Fractures
Why?
Do the results of HHR for fracture compel new thinking?
1. Tuberosity malposition, malunion, pull-off, lysis, non-
— New designs and materials in RBS prosthesis to enhance
union.
proximal bone adhesion and ingrowth in fractures and
• Factors
revisions
— Poor implant position
Comminuted, osteopenic fxs—Analgous to TEA for
— Poor tuberosity position
smashed distal humerus fx?
— Female
How to deteremine who might benefit form RBS vs. HHR?
— Age (>75)
— CT scan: muscle belly status
2. Elderly with poor cuff muscle function prior to fx
— Comminution
3. Poor compliance with rehab
— Age and Mental status
4. Complications
• How to salvage the salvage
Attempts to Reduce Poor Results
CHRONIC PROXIMAL HUMERUS FRACTURES
1. Better Tuberosity position
2. Better Tuberosity fixation Classsification of fracture sequelae. (Boileau)
• Technique Type I: Cephalic collapse or necrosis with minimal dis-
• Prosthesis tortion
• Aftercare Type II: Locked dislocation or fx/disloc
— Positioning: “Chase” the GT- Place in neutral (Apex Type III: Surgical Neck non-union
Sling) Type IV: Severe Tuberosity malunion

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
223
SYM 07:Layout 1 1/12/07 11:40 AM Page 224

If greater tuberosity osteotomy is required--- consider Type III: If good proximal bone stock: ORIF with bone
Reverse Prosthesis graft vs HHR
Type I and II: Hemiarthroplasty If proximal bone evacuation: consider HHR
If it is chronic anterior dislocation consider vs. reverse
reverse Type IV: Reverse Prosthesis
SYMPOSIA SHOULDER/ELBOW

REFERENCES 4. \mIn Reverse Shoulder Arthroplasty. Walch, Boileau, Mole, Favard, Levigne,
1. Boileau P, Chuinard C, Le Huec J-C, Walch G, Trojani C. Proximal Humerus Sirveaux (eds.). Sauramps Medical, 2006, Montpellier, France.
Fracture Sequelae. Impct of a new Radiographic Classification on Arthroplasty. 5. Frankle MA, Ondrovic LE, Markee BA, Lnace Harris M, Lee WE III. Stability of
Clin Orthop 442 ; 2006 : 121-130. tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder
2. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole D. Tuberosity malposi- Elbow Srug 2002; 11: 413-20.
tion and migration: Reasons for poor outcomes after hemiarthroplasty for dis- 6. Boileau P, Jacquot N, Kempf JF, Favard L, Le Huec JC, Mole D, Walch G. Results
placed fractures of the proximal humerus. J Shoulder Elbow Surg 2002; 11: 401- of the treatment of proximal humerus fracture with the use of a shoulder pros-
12. thesis specifically designed for fracture. Pp 380-381. In Shoulder Arthroscopy &
3. Sirveaux F, Navez G, Favard L, Boileau P, Walch G, Mole D. Reverse Prosthesis for Arthroplasty. Current Concepts 2004. Nice Shoulder Course. Sauramps Medical,
Acute Proximal Humerus Fracture, The Multicentric Study. Pp 73-80. 2004; Montpellier, France.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
224 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 225

SYMPOSIA SHOULDER/ELBOW
PREVENTION AND TREATMENT OF
COMPLICATIONS FROM ELBOW
FRACTURES: PEARLS AND PITFALLS (DD)
Moderator: Shawn W. O’Driscoll, MD, Rochester, MN (c - Acumed)

Elbow fractures, particularly when associated with high-energy injuries or osteoporosis, are
difficult to treat and prone to complications. We will focus on preventing and treating the
complications.

I. Complications of Distal Humerus Fractures

Mark S. Cohen, MD, Chicago, IL (n)

II. Complications of Coronal Shear Fractures

Michael McKee, MD, Toronto, ON Canada (a - Stryker Biotech Inc.)

III. Complications of Olecranon Fractures

Jesse B. Jupiter, MD, Weston, MA (a - AO Foundation, e - Wyeth Co, Amgen Co)

IV. Complications of Coronoid Fractures

David Ring, MD, Boston, MA (a - AO Foundation, Small Bone Innovations, Wright
Medical, Smith and Nephew Richards, b - AO North America, AO International,
c - Hand Innovations, d - Nexa Orthopaedics)

V. Complications of Radial Head and Neck Fractures

Shawn W. O'Driscoll, MD, Rochester, MN (c - Acumed)

VI. Discussion and Questions and Answers

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
225
SYM 07:Layout 1 1/12/07 11:40 AM Page 226

COMPLICATIONS OF DISTAL HUMERUS FRACTURES

Mark S. Cohen, MD
SYMPOSIA SHOULDER/ELBOW

The operative treatment of distal humerus fractures is associated type of fracture or type of surgical fixation used. Care must be
with a significant number of complications. As recently as 1969, taken to minimize soft-tissue stripping and judicious use of irri-
Riseborough and Radin stated that "open reduction and internal gation and possibly the pulse lavage may be beneficial.
fixation is not easy and would seem to offer little chance of a
good outcome." Although this concept has since been refuted Non-union/Loss of Fixation
with modern internal fixation techniques, several factors contin- Aseptic non-union of operatively treated Distal humerus frac-
ue to make these injuries difficult to treat. The bony anatomy of tures is rare, presumably due to the metaphyseal nature of the
the distal humerus is quite complex with little skeletal support of bone in this region and the excellent blood supply of the distal
the articular surfaces. When fractured, the fragments tend to be humerus. It is reported in 2-7% of distal humerus fractures treat-
small, are frequently fragmented and are largely covered in artic- ed operatively and is associated with high energy injuries and
ular cartilage. Furthermore, the muscular forces acting on the inadequate internal fixation. When non-union occurs, it can
fragments tend to rotate and displace them. Operative treatment include one of the intra-articular fragments, a separate epicondy-
of these injures requires stable internal fixation which must with- lar fragment or the olecranon osteotomy. Thin osteochondral
stand post-operative therapy during fracture consolidation. As fragments are also at risk for avascular necrosis and non-union.
one-half of body weight can be transmitted across the elbow dur- Treatment of non-union includes stable internal fixation in com-
ing normal daily activities, these loads can be considerable. bination with autogenous iliac crest bone grafting. When treated
in this manner, functional healing can be expected.
Pre-operative Planning
While is non-union is rare, hardware failure or loosening lead-
The first step in limiting intraoperative complications of distal
ing to malunion or requiring reoperation has been reported in
humerus fracture fixation involves careful pre-operative plan-
up to 15% of patients. This is associated with inadequate inter-
ning. It is essential to obtain good quality radiographs of the
nal fixation using screws alone or with the use of one-third
distal humerus before approaching these fractures surgically.
tubular plates rather than the 3.5 reconstruction or pre-con-
Due to the impaction of fracture fragments, this often requires
toured plates. In addition, elderly patients with poor bone stock
intraoperative traction films centered on the distal humerus
are at risk in whom the "low" transcondylar injuries occur with
(not on the antecubital fossa) once the patient is anaesthetized.
little distal bone for screw purchase. Judicious use of cancellous
Computed tomography with three-dimensional surface render-
bone graft when indicated may help avoid this problem.
ing can be helpful for more complex injuries.
Olecranon osteotomies fixed with two parallel K-wires rather
Operative fixation of distal humerus fractures requires a large
than a 6.5 mm cancellous screw have a much higher complica-
number of surgical tools, and one must not begin the operation
tion rate. In one series of 29 olecranon osteotomies for distal
without the necessary equipment. The small fragment set and
humerus fractures, 8 of the 9 reported complications occurred
the special 3.5mm reconstruction plates are needed for fixation
when the olecranon was fixed with the parallel K-wire tension
of the humerus. Alternatively, pre-countoured plates are now
band technique, including wire breakage and K-wire loosening
available for these periarticular elbow injuries. The large frag-
requiring removal. Due to this, some authors now advocate ole-
ment set with its 6.5mm cancellous screws is needed if one
cranon osteotomy fixation with a 6.5mm or 7.3 mm partially
plans an olecranon osteotomy and chooses screw fixation. Plate
threaded cancellous screw and a tension band wire. This screw
benders are required for the reconstruction plates and templates
should be of considerable length (90-110 mm) and should be
are helpful in contouring the plates to fit the complex geometry
predrilled prior to the osteotomy. Due to the 5-7o angulation of
of the distal humerus.
the olecranon with the long axis of the ulna, considerable
The trochlear diameter in the majority of individuals is greater torque must occasionally be applied to the screw during tight-
than 50mm, so extra long screws, if available, are helpful in frac- ening to properly reduce the osteotomy site. A chevron cut aids
tures requiring trochlear fixation. They are also helpful for the in reduction and provides a larger surface area for healing.
distal plate holes where screws can be driven up the medullary
canal of the humerus for added fixation. K-wires are needed for Ulnar Neuritis
provisional fixation and washers can be used to aid in the fixa- Distal humerus fractures are rarely associated with neurovascu-
tion of comminuted fragments and in osteoporotic individuals. lar injury. When nerve injury occurs, it is associated with high
A thin oscillating saw and osteotomes are required for an ole- energy trauma and most commonly involves the ulnar nerve.
cranon osteotomy if this approach is chosen. In addition, 1.0 or On the other hand, tardy ulnar neuropathy requiring surgical
1.2 mm gauge monofilament wire is needed to complete the intervention is reported in up to 15% of surgically treated cases.
tension band fixation. One must also have the instrumentation This complication can be avoided by judicious anterior ulnar
available to harvest iliac bone graft if needed. These fractures nerve transposition at the time of operative fixation. Indications
should only be approached by the experienced surgeon with the for nerve transposition include nerve contusion from injury or
aforementioned equipment readily available. if the nerve is in the vicinity of the hardware. As the cubital tun-
nel is often used for fixation of the medial column, most rec-
Infection ommend anterior transposition of the ulnar nerve anteriorly in
Infection following operative fixation of distal humerus fractures the majority of cases. This is especially important for low supra-
is fortunately uncommon. It is reported in 0-6% of patients and condylar ("transcondylar") injuries in the elderly.
is most often associated with open injuries. With 20-50% of dis-
tal humerus fractures being open, especially in young patients Loss of Motion
involved in high energy trauma, the infection rate is relatively Some loss of elbow motion is seen in virtually all intraarticular
low. The incidence of infection does not seem to be related to the fractures of the distal humerus requiring operative reduction
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
226 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 227

and stabilization. Causes include the initial soft tissue injury, the Heterotopic bone is also seen in greater than 90% of polytrau-
additional surgical trauma, inappropriately placed hardware ma patients with head injury and elbow fractures. In these
and inaccurate reduction of the fracture fragments. The elbow patients, ultimate elbow motion correlates inversely with the
must have both the coronoid and radial fossae anteriorly and extent of ectopic bone formed. Other factors associated with
the olecranon fossa posteriorly free of hardware or fracture frag- ectopic bone include a delay in post-operative mobilization and

SYMPOSIA SHOULDER/ELBOW
ments for maximum flexion and extension to occur. Similarly, if repeated surgical insults in the days to weeks following trauma.
the posterolateral plate is wrapped too far around the distal
Ectopic ossification is commonly seen on radiographs within
humerus, it can limit extension by impingement of the radial
three to four weeks of injury. The extent of bone formation is
head on the plate during extension. An inaccurate reduction can
usually evident by 12 weeks. The clinical presentation of hetero-
also limit elbow motion. Since the centers of rotation of the
topic ossification is increased pain and limitation of motion in
condyles lie on the same horizontal plane through the distal
the flexion-extension plane. Interestingly, rotation is rarely affect-
humerus, malalignment of one condyle with the other will lead
ed by heterotopic bone following fractures of the distal humerus.
to a loss of motion and potential intrinsic elbow instability.
Once present, heterotopic ossification is irreversible and any
Prolonged immobilization is strongly correlated with post-oper-
attempts at elbow mobilization only exacerbate the process.
ative stiffness. Following stable fixation with early mobilization,
Due to this, high risk patients operated on late or with head
elbow flexion returns earliest and plateaus in the first two to three
injury should be treated with aggressive heterotopic ossification
months. The average flexion reported after internal fixation of
prophylaxis. A typical protocol involves one 700 cGy dose of
these injuries is 125o with a range of 110-140o. Elbow extension
external beam radiation to the elbow within 24 hours of sur-
lags behind and can improve up to 4-6 months post-operatively.
gery,and/or a short period of non-steroidal anti-inflammatory
The vast majority of patients lose terminal extension, with an
medication. Recent evidence suggests that a limited two week
average fixed flexion contracture of 20-30o at follow-up. The loss
course of non-steroidal treatment is effective in this regard.
of flexion and extension has been correlated with the severity of
There is no evidence to suggest that either modality will clini-
the fracture and the age of the patient. In one series, no patient
cally delay wound or fracture healing.
over the age of 45 years regained more than 120o of total motion.
Although stiffness is a common complication, symptomatic Pain/Degenerative Arthritis
post-operative joint instability or laxity is rare. In addition, Exertional pain is reported in up to 25% of patients following
supination and pronation are usually unaffected. This is a radio- intra-articular distal humerus fractures. The etiology of the pain
capitellar function and full return of elbow rotation is common is not entirely clear. Early degenerative changes can result from
following these injuries. articular damage at the time of injury. It can also be secondary to
and accelerated by a non-anatomic reduction. Although the clin-
Heterotopic Ossification ical result does not always correlate with the roentgenographic
Heterotopic ossification is reported in up to 8% of fractures of findings at follow-up, some degree of post-traumatic arthritis can
the distal humerus. Severe soft tissue trauma about the elbow be seen in up to 65% of patients at an average 5 year follow-up.
appears to be a prerequisite. In the elbow, ectopic bone forms in
A general rule is that articular loss can be better tolerated than
both the ligaments and the joint capsule and can severely com-
articular incongruity. Thus, every attempt must be made to
promise post-operative range of motion.
obtain an anatomic reduction of the articular surface during
A delay in operative fixation of more than five days may be asso- internal fixation.
ciated with the development of heterotopic ossification.

REFERENCES 12. McKee MD, Jupiter JB: Trauma to the adult elbow and fractures of the distal
1. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus, in Browner B (ed): Skeletal Trauma. Philadelphia, PA, WB Saunders,
humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832. 1998, vol 2, pp 1455-1522.
13. McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH: Functional
2. Cohen MS, Heterotopic Ossification of the Elbow, IN The Stiff Elbow, Ed. Jesse B.
outcome after open supracondylar fractures of the humerus. J Bone Joint Surg Br
Jupiter, American Academy of Orthopaedic Surgeons, Rosemont, 31-40, 2006.
2000;82:646-651.
3. Cohen MS, Hastings H II: Post-traumatic contracture of the elbow: Operative
14. McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional out-
release using a lateral collateral ligament sparing approach. J Bone Joint Surg Br
come following surgical treatment of intra-articular distal humeral fractures
1998;80:805-812.
through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.
4. Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechani-
15. O’Driscoll SW: The triceps-reflecting anconeus pedicle (TRAP) approach for distal
cal comparison of methods. J Orthop Trauma 1990;4: 260-264.
humeral fractures and nonunions. Orthop Clin North Am 2000;31:91-101.
5. Jupiter JB, Neff U, Regazzoni P, Allgower M: Unicondylar fractures of the distal
16. O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD: Difficult Elbow
humerus: An operative approach. J Orthop Trauma 1988;2: 102-109.
Fractures: Pearls and Pitfalls, IN Instructional Course Lectures, Ed. D.C. Ferlic,
6. Jupiter JB, Neff U, Holzach P, Allgower M: Intercondylar fractures of the American Academy of Orthopaedic Surgeons, Rosemont, 52:113-136, 2003.
humerus: An operative approach. J Bone Joint Surg Am 1985;67:226-239. 17. O’Driscoll S, Sanchez-Sotelo J, Torchia ME: Management of the smashed distal
7. Jupiter JB: Complex fractures of the distal part of the humerus and associated humerus. Orthop Clin North Am 2002;33:19-33.
complications. Instr Course Lect 1995;44:187-198. 18. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW: Principle-based internal fixation of
8. Kasser JR, Richards K, Millis M: The triceps dividing approach to open reduction distal humerus fractures: Tech Hand Upper Extrem Surg 2001;5:179-187.
of complex distal humeral fractures in adolescents: A Cybex evaluation of triceps 19. Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of
function and motion. J Pediatr Orthop 1990;10:93-96. internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
9. McKee MD, Jupiter JB: A contemporary approach to the management of complex 20. Thompson HC III, Garcia A: Myositis ossificans: Aftermath of elbow injuries.
fractures of the distal humerus and their sequelae. Hand Clin 1994;10:479-494. Clin orthop 1967;50:129-134.
10. McKee M, Jupiter J, Toh CL, Wilson L, Colton C, Karras KK: Reconstruction after 21. Zagorski JB, Jennings JJ, Burkhalter WE, Uribe JW: Comminuted intraarticular
malunion and nonunion of intra-articular fractures of the distal humerus. J Bone fractures of the distal humeral condyles: Surgical vs nonsurgical treatment. Clin
Joint Surg Br 1994;76:614-621. Orthop 1986;202:197-204.
11. McKee MD, Jupiter JB, Bosse G, Goodman L: Outcome of ulnar neurolysis during 22. Waddell JP, Hatch J, Richards R: Supracondylar fractures of the humerus: Results
post-traumatic reconstruction of the elbow. J Bone Joint Surg Br 1998;80:100-105. of surgical treatment. J Trauma 1988;28:1615-1621.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
227
SYM 07:Layout 1 1/12/07 11:40 AM Page 228

CORONAL SHEAR FRACTURES OF THE DISTAL HUMERUS –

“PITFALLS AND PEARLS”
SYMPOSIA SHOULDER/ELBOW

Jesse B. Jupiter, MD

I. Overview — Suggested for patients who are infirmed

A. The problem –articular fractures with meager subchon- 2. Disadvantages – block to motion, potential for insta-
dral bony support and limited soft tissue attachments bility
B. Pitfalls
V. Operative exposure
1. Fracture recognition
A. Pitfalls
2. Decision making
1. Shearing fractures are anterior and often displaced
3. Operative approach
proximally
4. Tactics of internal fixation
2. Ulnar nerve dysfunction may prove difficult post-
5. Postoperative management
operatively
6. Complications
B. Pearls
7. Outcomes
1. Straight dorsal incision will permit mobilization of
II. Clinical Case (operative video) the ulnar nerve 6 cm proximal and distal to the
cubital tunnel
III. Fracture morphology – recognition
2. Extended lateral approach (will be demonstrated)
A. Pitfalls
3. Lateral epicondyle osteotomy may enhance lateral
“We have been treating many such fractures and they are
exposure and allow elbow to hinge open on medical
for the most part capitellar lesions with some trochlear
soft tissue structures
involvement:.” Letter to the editor J. Bone Joint Surgery
in response to article by Ring and Jupiter “Complex artic- VI. Internal Fixation
ular fractures of the distal humerus”. JBJS 4A:2003 A. Pitfalls
B. Pearls 1. Small articular fragments with little subchondral bone
1. Double crescent sign on standard lateral radiograph or attached soft tissue
2. CT scanning especially 3-dimensional reconstructions 2. Fixation may be necessary from anterior through the
3. Fracture patterns important due to individual differences overlying articular cartilage
Type 1 Standard capitellum fracture 3. Underlying osteoporosis will complicate fixation
Type 2A Coronal shear fracture-single fragment B. Pearls
Type 2B Coronal shear fracture-multifragmented 1. Headless screws are essential for most fracture patterns
Type 3 Coronal shear fracture plus lateral epicondyle 2. Lateral epicondylar fracture and/or osteotomy can be
fracture secured with small plate and/or tension wire
Type 4 Type 3 fracture with impaction of posterior lat- 3. Type 6 can benefit from small plate support on the
eral column columns
Type 5 Shearing fracture of anterior and posterior
VII. Complications
trochlea fragments
1. Ulnar nerve dysfunction
Type 6 Extension to medial epicondyle
2. Loss of fixation
IV. Decision making 3. Loss of motion
A. Operative treatment 4. Deformity
1. Advantages – restore anatomy and stability on perma-
VIII. Outcomes – Ring D, Jupiter J. JBJS 85A 2003
nent basis
21 Patients
2. Disadvantages – loss of motion, prolonged rehab, loss
All united, no instability
of fixation
10 had second procedure
B. Arthroplasty
6 capsular release
1. Advantages – early return to function and enhanced
2 ulnar nerve transpositions
motion
2 hardware removal
2. Disadvantages – permanent limitation on function,
Average arc of motion 96º (range 55-140º)
risk of loosening and failure
Mayo index - Excellent 4
C. Closed treatment
- Good 12
1. Advantages – reduction may be applicable for capitel-
- Fair 5
lar fracture only

REFERENCES 4. Ring D, Jupiter J, Gulotta L. Articular fractures of the distal part of the
1. Gejrut W. On Intraarticular fractures of the capitellum and trochlea of humerus. J. Bone Joint Surg 2003;85A:232-38.
the humerus with special reference to treatment. Acta Chir Scand 5. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the
1932;71:253-70. distal end of the humerus. J. Bone Joint Surg 1996;78:49-59.
2. Jupiter JB, Barnes KA, Goodman LF, Saldana AE. Multiplane fracture of 6. Opprenheim W, Davlin LB, Leipzig JM, Johnson EE. Concomitant frac-
the distal humerus. J. Orthop Trauma 1993;7:216-20. tures of the capitellum and trochlea. J Orthop Trauma 1989;3:260-2.
3. Husband JB, Hastings H. The lateral approach for operative release of 7. Robertson RC, Bogart FB. Fracture of the capitellum and trochlea com-
posttraumatic contracture of the elbow. J. Bone Joint Surg bined with fracture of the external humeral condyle. J. Bone Joint Surg
1990;72:1323-8. 1933:15:206-13.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
228 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 229

COMPLICATIONS OF CORONOID FRACTURES

David Ring, MD

SYMPOSIA SHOULDER/ELBOW
O’Driscoll1 Type 1—Transverse tip fracture ¬ Errant hardware
• Anatomy • Tips for avoiding complications
— Average 39% total bony height of coronoid2 — 3D CT to be sure there is no subluxation if treating non-
— Includes anterior capsular insertion2-4 operatively.
• Injury Characteristics — Operative treatment
— Usually associated with terrible triad injuries4 ¬ Leave ulnar nerve in situ, or
¬ Complete dislocation of the elbow ¬ Suture skin to fascia to retract ulnar nerve anteriorly if
¬ Fracture of the radial head transposed (avoid prolonged traction on the nerve
¬ Fracture of the Coronoid through a tape).
— Occasionally seen with ¬ Use suture grasping capsule for small fragments
¬ Posterior olecranon-fracture dislocations4
O’Driscoll Type 3—Large Basal Coronoid Fractures
¬ Diaphyseal posterior Monteggia lesions—transitional
• Anatomy
lesion
— Three large fragments (anteromedial, central, lesser sig-
• Complications
moid notch)
— Of undertreatment
— Can also have a tip fragment.
¬ Instability: Subluxation/dislocation5, 6
— Can be more comminuted.
¬ Articular injury/arthrosis
— There may be lost or unreconstructable fragments.
— Of treatment
• Injury Characteristics4, 8
¬ Fixation failure
— Usually associated with olecranon fracture-dislocations
¬ Heterotopic ossification?
Anterior olec fx-disloc Posterior olec fx-disloc
• Tips for avoiding complications
MCL Intact Intact
— Suture rather than screw fixation LCL Intact Avulsed in 60%
— Preservation of radiocapitellar contact6, 7 Coronoid Simple Comminuted in > 50%
¬ ORIF radial head Radial head fx No Yes
¬ Radial head replacement
• Complications
— Reattachment of the LCL to the lateral epicondyle
— Of undertreatment
— Selective use of MCL repair and hinged external fixation
¬ Instability: Subluxation/dislocation
¬ If treated greater than 2 weeks after injury, use a hinge
¬ Articular injury/arthrosis
— In desperation—Cross pinning of joint
¬ Stiffness
O’Driscoll Type 2—Anteromedial facet fracture — Of treatment
• Anatomy ¬ Fixation failure
— Subtypes ¬ Instability/subluxation/arthrosis
Relationship to insertion of Tip fracture • Tips for avoiding complications
anterior band of MCL — Access and techniques to reduce and repair coronoid
1 Above No — Dorsal contoured plate9
2 Above Yes — Long plate
3 Below Yes — Use wire or suture through soft tissue attachments of
• Injury Characteristics4 small, comminuted, or osteoporotic fragments
— LCL injury, or — Preservation of radiocapitellar contact
— Olecranon fracture, or ¬ ORIF radial head
— Second larger coronoid fracture ¬ Radial head replacement
• Complications of — Reattachment of the LCL to the lateral epicondyle
— Undertreatment — Hinged external fixation for
¬ Stiffness/pain ¬ Comminuted fractures
¬ Instability ¬ Instability
¬ Arthrosis ¬ Delayed treatment of complex fractures (> 2 weeks
— Treatment later)
¬ Ulnar neuropathy

REFERENCES 6. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures
1. O'Driscoll SW, Jupiter JB, Cohen M, Ring D, McKee MD. Difficult Elbow of the coronoid and radial head. J Bone Joint Surgery 2002;84A:547-551.
Fractures: Pearls and Pitfalls. Instructional Course Lectures 2003;52:113-134. 7. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical pro-
2. Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible-triad tocol to treat elbow dislocations with radial head and coronoid fractures. J Bone
injuries. J Hand Surg [Am] 2006;31(5):794-7. Joint Surg 2004;86A(1122-30.).

3. Cage DJN, Abrams RA, Callahan JJ, Botte MJ. Soft tissue attachments of the ulnar 8. Doornberg J, Ring D, Jupiter J. Effective treatment of fracture-dislocations of the
coronoid process. Clin Orthop 1995;320:154-158. olecranon requires a stable trochlear notch. Clin Orthop Relat Res.
2004;435:276-7.
4. Doornberg JN, Ring D. Coronoid fracture patterns. J Hand Surg [Am]
2006;31(1):45-52. 9. Ring D, Kloen P, Tavakolian J, Helft D, Jupiter JB. Loss of alignment after opera-
tive treatment of posterior Monteggia fractures: salvage with dorsal contoured
5. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and plate fixation. J Hand Surg [Am] 2004;29:694-702.
intraarticular fractures. Clin Orthop 1989;246:126-130.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
229
SYM 07:Layout 1 1/12/07 11:40 AM Page 230

PITFALLS AND COMPLICATIONS OF RADIAL

HEAD AND NECK FRACTURES
SYMPOSIA SHOULDER/ELBOW

Shawn W. O'Driscoll, MD

\Diagnosis • Replacement
• Incomplete — Design
• Missed associated injuries ¬ Head Shape
¬ Head Sizes
Classification
¬ Stem Sizes – length, diameter, shape
Imaging ¬ Materials
• CT ¬ Stem Fixation – loose, ingrowth, cemented
¬ Modularity
Indications For Surgery
– Monopolar
• Displacement
– Bipolar
• # pieces
– Assembly before / after implantation
• Associated injuries
— Implantation
— MCL
¬ Position
— Essex-Lopresti
¬ Orientation
— Coronoid
¬ Method of insertion
Surgical Treatment – Ligament sparing vs. takedown
• Excision ¬ Problem of overstuffing
• Partial Excision • Management of Other Injuries
• ORIF • Post-op Management
— Technique
— Choice of hardware
— Screws vs. plates
— Safe Zone
— Neck Fixation

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
230 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 231

SYMPOSIA SPORTS/ARTHROSCOPY
◆ MRI - ARTHROSCOPY CORRELATION (J)
Moderator: Mark D. Miller, MD, Charlottesville, VA (n)

This symposium will present the basics of MRI and arthroscopic images of Shoulder, Knee,
Hip, and Elbow sports injuries and correlate them with your input.

I. MRI Overview
Timothy G. Sanders, MD, Keswick, VA (n)

II. Arthroscopic Overview

Mark D. Miller, MD, Charlottesville, VA (n)

III. Shoulder Cases—MRI and Arthrscopy

Stephen S. Burkhart, MD San Antonio, TX (c, e - Arthrex, Inc.)
and Timothy G. Sanders, MD, Keswick, VA (n)

IV. Knee Cases—MRI and Arthroscopy

Mark W. Anderson, MD Charlottesville, VA (n)
and Mark D. Miller, MD Charlottesville, VA (n)

V. Hip & Elbow Cases—MRI and Arthroscopy

Mark R. Safran, MD, San Francisco, CA (a - Smith and Nephew, Breg, Histogenics)
and David Stoller, MD, Tiburon, CA (n)

VI. Audience Participation

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
231
SYM 07:Layout 1 1/12/07 11:40 AM Page 232

THE BASICS OF MR IMAGING: WHAT THE ORTHOPEDIC

SYMPOSIA SPORTS/ARTHROSCOPY

SURGEON NEEDS TO KNOW

Timothy G. Sanders, MD

MR Physics: The Basics Pulse Sequence

MR imaging uses a strong magnet combined with a radiofre- Series of RF pulses used to create an image with predictable
quency (RF) transmitter and receiver (the coil) to create an image qualities.
image which is based upon the content of hydrogen protons of
T1-weighted image
the soft tissues (fat and water molecules). MR imaging has rev-
• The anatomy image: high signal to noise, usually the best
olutionized orthopedic imaging as it provides superb soft tissue
image for depicting anatomy, but displays pathology poorly
contrast and resolution and multiplanar capabilities allowing a
• Fat: high signal (bright on image)
noninvasive means or evaluating muscles, tendons, ligaments
• Water/muscle: intermediate signal
and articular cartilage.
• Calcium/fibrous tissue: low signal
The Magnet T2-weighted image
• High field versus low field • The pathology image: usually the best image for depicting
• The strength of the magnet is proportional to the signal-to- pathology
noise ratio. • Fat: bright signal (unless using a fat saturation technique)
High field Low field • Water: high signal (bright)
> 1 Tesla <0.5 Tesla • Muscle: intermediate signal
Whole body scanner Extremity scanner • Calcium/fibrous tissue: low signal
Closed system: claustrophobia (10%) Open system: less constrained by
body size
Signal rich images Signal poor images

SNR,
contrast,
resolution Longer scan times/ motion artifact

T1: fat bright; Water intermediate T2: fat suppressed; Water bright
Proton density image
• Intermediate between T1 and T2 (high signal to noise, and
shows pathology)
• Fluid and fat: high signal (bright)
Low field strength image: SST tear High field strength image: SST tea
• Muscle intermediate
• Excellent for cartilage evaluation when PD combined with
Low field image “less pretty” fat saturation
• Diagnosis of meniscal pathology and rotator cuff pathology
is equivalent. Gradient Echo image
• High field images provide improved accuracy for cartilage • The high resolution image
and labral lesions. • 3-D volume imaging
• 1-mm slice thickness
The Coil • Cartilage, intrinsic ligaments of wrist, small anatomic struc-
• The coil is defined as the RF transmitter/ receiver that listen tures
for the signal to create the MR image. Two types of coils are
generally available for MR imaging.
• Body coil: usually contained within the shell of the magnet,
large and far from patient, used for imaging large body
parts (abdomen, thorax, pelvis, etc).
• Surface coil: small device placed on the body part being
imaged. Surface coils are typically used to image small body
parts such as a joint. The smaller the coil and the closer the
Proton density with fat saturation Gradient echo imaging: high resolution
coil is to the anatomy, the better the quality of the image.
Regardless of magnet type, surface coils are a must in Fat saturation
extremity imaging! A technique used to subtract out bright signal from fat. Makes
water signal more conspicuous. Fat saturation is nearly always
applied to T2-weighted images in orthopedic imaging to
improve the conspicuity of pathology. Also, fat saturation is
applied to T1-weighted images to increase visualization of IV or
intraarticular contrast (gadolinium).

Surface coils (wrist) (Shoulder)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
232 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 233

• Heterogeneous fat saturation

— Can mask or mimic pathology.

SYMPOSIA SPORTS/ARTHROSCOPY
T2 no fat saturation T2 image with fat sat (notice increased
conspicuity of marrow edema)
Contrast Agents (gadolinium) • Motion artifact
Orthopedic uses — Can mimic meniscal tear; if motion artifact present, must
• IV gadolinium used to differentiate cystic from solid lesion. repeat meniscal images to prevent miscalling meniscal
• MR arthrography pathology.
— Direct: intraarticular gadolinium
— Indirect: IV gadolinium given to provide enhancement of
intraarticular structures

Motion artifact mimicking meniscal tear

Safety
RF energy deposition
High signal lesion: cyst or solid? Diffuse enhancement with Gad= • Can cause burns
solid lesion • Coiled wires/ tattoos
• Stop scan immediately if patient complains of heat or warm
sensation
Metal implants or devices
• Contraindicated
— Shrapnel in eye or spine: screen with radiographs
— Pacemaker
— Cochlear implants
Intraarticular gadolinium increases conspicuity of subtle internal derangement — Neural stimulator
(labral tears of shoulder, hip, postoperative meniscal tears, etc).
— Ferromagnetic aneurysm clip
Artifacts — External fixators
• Magic angle • Safe
— T1 phenomenon: Increased T1 signal within structures — Arthroplasty
that are oriented at 55° to main magnetic field. Can — Internal rods, pins, screws, plates, etc
mimic pathology, rotator cuff, tendons about ankle; sig- • Moderate risk
nal normal on T2 images. — Vascular stints: some recommend waiting 6-8 weeks fol-
• Susceptibility artifact lowing placement to allow time to granulate in.
— Artifact caused by metal or other ferromagnetic material
Specific recommendations for particular devices can be
in patient. Can distort image quality.
researched on MRIsafety.com
• This website provides a comprehensive list of medical
devices and discusses the safety issues regarding MRI scan-
ning of these devices.

Suggested Readings 3. MRIsafety.com Website that lists all medical devices and states whether the spe-
1. Sanders TG, Miller MD. A Systematic Approach to Magnetic Resonance Imaging cific device is safe for MR imaging.
Interpretation of Sports Medicine Injuries of the Shoulder. Am J Sports Med 4. Imaging of the Upper Extremity. Clin Sports Med, 25(3), Jul 2006.
33:1088-1105, July 2005. 5. Imaging of the Lower Extremity. Clin Sports Med, 25(4), Oct 2006.
2. Sanders TG, Miller MD. A Systematic Approach to Magnetic Resonance Imaging 6. “Imaging of Sports Medicine Injuries” in Orthopaedic Sports Medicine,
Interpretation of Sports Medicine Injuries of the Knee. Am J Sports Med. Principles and Practice, 2nd Edition. Jesse C. DeLee, David Drez, J., Mark D.
33(1):131-148, Jan-Feb 2005. Miller eds., W.B. Saunders Company, Philadelphia, PA., 2003, 2nd edition, pages
557-596.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
233
SYM 07:Layout 1 1/12/07 11:40 AM Page 234

ARTHROSCOPIC OVERVIEW
SYMPOSIA SPORTS/ARTHROSCOPY

Mark D. Miller, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
234 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:40 AM Page 235

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
235
SYM 07:Layout 1 1/12/07 11:40 AM Page 236

HIP ARTHROSCOPY
SYMPOSIA SPORTS/ARTHROSCOPY

Mark D. Miller, MD

Figures reproduced with permission from:

1. Byrd JWT. Hip Arthroscopy in Miller MD and Cole
BJ (eds) Textbook of Arthroscopy, Philadelphia:
Elsevier, 2004.
2. Miller MD, Howard RF, Plancher KD. Surgical Atlas
of Sports Medicine, Philadelphia: Elsevier, 2003.
3. Miller MD, Osborne FR, Warner JJP, Fu FH. MRI-
Arthroscopy Correlative Atlas, Philadelphia: Elsevier,
1997

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
236 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 237

ELBOW ARTHROSCOPY
Elbow Arthroscopy

SYMPOSIA SPORTS/ARTHROSCOPY
AAOS MRI-Arthroscopy Correlation
Mark D. Miller, MD Sypmosium
Mark D. Miller, MD, Professor, UVA Orthopaedics
POSITIONING1,2

PORTAL PLACEMENT1

VISUALIZATION2

Figures reproduced with permission from: 2. Miller MD, Howard RF, Plancher KD. Surgical Atlas of Sports Medicine,
1. Hsu JC and Yamaguchi K. Elbow Arthroscopy in Miller MD and Cole BJ (eds) Philadelphia: Elsevier, 2003.
Textbook of Arthroscopy, Philadelphia: Elsevier, 2004.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
237
SYM 07:Layout 1 1/12/07 11:41 AM Page 238

THE SHOULDER: MRI-ARTHROSCOPY CORRELATION

SYMPOSIA SPORTS/ARTHROSCOPY

Stephen S. Burkhart, MD, Timothy G. Sanders, MD

Rotator Cuff • Full thickness tear: T2 fluid signal completely through ten-
don, superior to inferior
MRI Findings
— Size and location of tear, retraction of tendon end,
Normal
delamination, fatty atrophy
The normal rotator cuff tendon should appear dark on all MR
• Subscapularis tear: best depicted in axial plane (associated
pulse sequences and should completely cover the humeral
with LHBT dislocation)
head. The supraspinatus and infraspinatus tendons are best
• Calcific tendinosis: Globular low T1, T2 signal within ten-
depicted in the coronal and sagittal imaging planes, while the
don with surrounding edema
subscapularis tendon is best depicted in the axial imaging plane.

Tendinosis, SST PASTA lesion, SST

Normal SST (Coronal) Normal Cuff (Sagittal)

Interstitial tear, SST

Normal Subscapularis (axial)

Pathology
• Tendinosis: thickened tendon, intermediate T1 and T2 sig-
nal abnormality
• Partial thickness tear
— Articular: T2 fluid signal extending into articular surface
of tendon
— PASTA (Partial Articular-sided Supraspinatus Tendon Full thickness tear/retraction, SST Subscap tear/retraction (LHBT dislocation)
Avulsion) T2 fluid extending partially through articular
surface of SST at anterior attachment site
— Interstitial: T2 fluid signal within substance of tendon,
no extension to surface
— Bursal: T2 fluid signal extending into bursal surface of
tendon

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
238 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 239

MRI/ARTHROSCOPY CORRELATION

SYMPOSIA SPORTS/ARTHROSCOPY
Mark D. Miller MD, Mark Anderson MD

Postero-Lateral Corner Injury

Arthroscopic image of ACL pseudolaxity secondary to PCL tear

“sloppy ACL” sign (B). The ligament was clearly laxed when
probed. Final arthroscopic view of the posterior cruciate graft
(C).

Acute Patella Dislocation

Coronal fat saturated T2W images reveal complete disruption of

all lateral supporting structures: biceps femoris(A); LCL and
popliteus tendon (B); iliotibial tract (C). Axial (A) and Sagittal (B) fast spin echo fat saturated T2 weight-
ed images reveal contusions involving the medial patella and
lateral femoral condyle, typically seen after lateral patellar dislo-
cation. Note also the large articular cartilage defect along the
medial patellar facet and corresponding displaced osteochon-
dral fragment in the lateral patellofemoral gutter.

Arthroscopic view from the anterolateral portal demonstrating

marked opening (much > 1cm) of the lateral compartment with
varus stress (Figure C) suggesting a PLC injury. This was con-
firmed with open surgical dissection (Figure D) demonstrating
a complete tear of the LCL (probe) and the entire posterolater-
al complex.

Posterior Cruciate Ligament Injury

Arthroscopic image of loose body in the lateral gutter. (C) This

represents the osteochondral fragment from the acute patella
dislocation. Arthroscopic view of the donor site on the patella
(D). Repair of the medial patellofemoral ligament (E).

Sagittal fat saturated T2W image demonstrates a tear of the pos-

terior cruciate ligament (full thickness at arthroscopy) and an
anterior tibial contusion often seen with these injuries due to a
typical “dashboard” mechanism of injury.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
239
SYM 07:Layout 1 1/12/07 11:41 AM Page 240

Anterior Cruciate Ligament Injury

SYMPOSIA SPORTS/ARTHROSCOPY

Coronal (A, B) and sagittal (C) fast spin echo fat saturated T2
weighted images reveal a focal area of full thickness cartilage
loss along the posterior weight-bearing surface of the lateral
femoral condyle in this patient with numerous subchondral
infarcts.

Sagittal (A) and axial (B) fat saturated T2W images reveal a com-
plete proximal tear of the anterior cruciate ligament. Associated
lateral compartment bone marrow contusions are also present
(C) Arthroscopic images of the chondral defect after careful debride-
ment (D). Final athroscopic appearance after osteochondral
autologous plug transfer (E).

Bucket-Handle Tear of the Medial Meniscus

Coronal (A) and sagittal (B) fast spin echo fat saturated T2
weighted images reveal a large bucket handle tear of the medial
meniscus with a displaced fragment within the notch and trun-
cation of the body of the meniscus (short arrow). Note also the
Arthroscopic view of the notch showing complete disruption of “double PCL sign on the sagittal view (P = posterior cruciate lig-
the anterior cruciate ligament (D). ACL graft being passed into ament).
the femoral tunnel and tensioned at the time of the ligament
reconstruction procedure (E). Final arthroscopic view of the
new ACL graft (F).

Femoral Condyle Cartilage Injury

Image of a bucket handle meniscal tear which is flipped into the

notch on the arthroscopic view (C). Final view of the inside-out
meniscus repair after reduction of the displaced fragment (D).

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
240 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 241

HIP AND ELBOW

SYMPOSIA SPORTS/ARTHROSCOPY
David Stoller, MD, Marc R. Safran, MD

I. HIP 2. Visualize Laterally

a. Introduction 3. Visualize Inferiorly
b. MRI viii. Anterolateral Portal
i. Surface coil 1. Visualize Anterior
1. Specialized coils include 4 and 8 channel torso 2. Visualize Posterior
coils. ix. Posterior Portal
2. Best quality images from 4 channel phased array 1. Visualize Anterior
cardiac coil. 2. Visualize Laterally
3. 8 channel dual dedicated hip coil will be available 3. Visualize Posteromedially / inferiorly
in 2007. b. 30 degree lens
ii. Pulse sequences i. Articular surface acetabulum
1. Coronal STIR or FS PD FSE bilateral ii. Articular surface femoral head
2. Coronal, axial, and sagittal T1 or PD FSE, and FS iii.Fovea
PD FSE unilateral iv. Ligamentum Teres
iii.MR arthrogram v. Transverse Acetabular Ligament
1. Indication: Increased conspicuity of labral and vi. Anterior Portal
chondral lesions by producing capsular distention 1. Visualize Medially (best)
2. Simultaneous of injection of local anesthetic (pain 2. Visualize Inferiorly
test). 3. Visualize Posteriorly
3. Important to have fluid sensitive sequences in addi- vii. Anterolateral Portal
tion to FS T1. 1. Visualize Central Fossa
4. Coronal FS PD FSE bilateral 2. Visualize Anterior
5. Coronal T1 and FS PD FSE unilateral 3. Visualize Posterior
6. Axial FS T1 and FS PD FSE unilateral viii. Posterior Portal
7. Sagittal FS PD FSE unilateral 1. Visualize Central Fossa
iv. Other techniques 2. Visualize Anteriorly
1. Axial oblique 3. Visualize anterolaterally
a. Alpha angle measurement 2. Peripheral Compartment
2. Radial imaging a. 30 degree lens
a. Optional for anterior labrum i. Anterior neck area
3. Cartilage imaging ii. Medial neck area
a. T2 mapping iii.Medial head area
v. Checklist (best imaging plane) iv. Anterior head area
1. Labrum v. Lateral head area
a. Sagittal for anterior and posterior labrum vi. Lateral neck area
b. Coronal for chondrolabral junction and lateral vii. Posterior area.
labrum ii. Pathologies
2. Cartilage best with FS PD FSE 1. Labral Tear
3. Subchondral bone sclerosis best seen on T1 a. Chondrolabral Junction
4. Acetabular morphology b. Cleavage Tears
a. Shallow on anterior coronal images in DDH c. Perilabral Cysts
b. Labral hypertrophy in DDH
5. Transverse ligament
a. Sagittal
6. Ligament teres
a. Coronal
b. Axial
7. Capsule
a. All three planes
c. Arthroscopy
i. Normal Hip Anatomy
1. Central Compartment
a. 70 degree lens
i. Most useful centrally Femoroacetabular Impingement with Chondral damage
ii. Peripheral labrum
2. Femoroacetabular Impingement
iii.Articular surface acetabulum
a. CAM
iv. Articular surface femoral head
i. Delamination Chondral Lesion
v. Capsule
b. Pincer
vi. Centrally
i. Chondral Lesion more peripheral
vii. Anterior Portal
c. Combination
1. Visualize Medially
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
241
SYM 07:Layout 1 1/12/07 11:41 AM Page 242

d. Arthritic Change 1. Coronal

e. Subchondral Cyst 2. Axial
f. DDH 3. Sagittal
SYMPOSIA SPORTS/ARTHROSCOPY

4. T1 or PD FSE
5. FS PD FSE
ii. Checklist (best imaging plane)
1. Common extensor and flexor tendons - Coronal
2. Radial collateral ligament and lateral ulnar collater-
al ligament - Coronal
3. Anterior bundle of the ulnar (medial) collateral lig-
ament - Coronal
4. Radiocapitellar articulation - Sagittal
5. Olecranon and trochlear articulation (Coronoid
Fossa, Olecranon fossa) - Sagittal
6. Neurovascular bundle
Femoroacetabular Impingement with Chondral-Labral Delamination Injury a. Ulnar nerve – Axial, Coronal
b. Medial nerve - Axial
3. Chondral Lesions
c. Radial nerve - Axial
a. Isolated
7. Tendons
4. Loose Bodies
a. Biceps - Axial, Sagittal
a. Foveal
b. Brachialis – Axial, Sagittal
b. Peripheral compartment
c. Triceps - Sagittal
5. Synovial Disease
d. Synovial fringe - Coronal
a. Synovial Chondromatosis
e. Loose bodies – Axial, Sagittal
b. Synovial Osteochondromatosis
c. Arthroscopy
c. PVNS
i. Normal Elbow Anatomy
1. Anterior Compartment
a. Proximal Medial Portal
i. Radiocapitellar joint
ii. Lateral Capsule
iii.Superior Capsule
iv. Distal Humerus
v. Proximal Radioulnar Joint
vi. Coronoid Process / Fossa
vii. Trochlea
b. AnteroLateral Portal
i. Trochlea
Loose Bodies associated with Synovial Chondromatosis
ii. Coronoid Process
iii.Coronoid Fossa
6. Benign Lesions iv. Medial Capsule
a. Osteochondroma v. Superior Capsule
b. Osteoid Osteoma c. Proximal Lateral Portal
7. Instability i. Trochlea
8. Normal Variants ii. Coronoid Process
a. Triirradiate Cleft / Physeal Scar iii.Coronoid Fossa
b. Stellate Crease iv. Medial Capsule
c. Sublabral Cleft v. Anterolateral Radial Head / capitellum
d. Supraacetabular Fossa 2. Straight Lateral
a. Capitellum
b. Posterior Radial Head
c. Radioulnar Joint
d. Olecranon
e. Trochlear notch
3. Posterior Compartment
a. Central Posterior Portal
i. Olecranon Tip
ii. Olecranon Fossa
iii.Posteromedial Gutter
iv. Posterolateral Gutter
b. Posterolateral Portal
Supraacetabular Fossa i. Olecranon Tip
ii. Olecranon Fossa
2. ELBOW iii.Posterolateral Gutter
a. Introduction iv. Posterior Trochlea
b. MRI ii. Pathologies
i. Pulse sequences 1. Lateral Epicondylitis
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
242 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 243

2. Ulnar Collateral Ligament Injury

3. Loose Bodies
4. Valgus Extension Overload Syndrome

SYMPOSIA SPORTS/ARTHROSCOPY
5. Posterolateral Rotatory Instability
6. Biceps Tendon

Extensor Muscle Tendinosis and Capsular Rent

3. Conclusion
a. MRI is particularly useful tool
i. To evaluate pathology
ii. Identify lesions pre-operatively
Anterior Loose Body from OCD of the Elbow 1. Plan surgery
2. Determine prognosis
3. Assess Extraarticular pathology
4. Identify pathology that may be in hard to see areas
of the hip and elbow.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
243
SYM 07:Layout 1 1/12/07 11:41 AM Page 244

SYMPOSIA SPORTS/ARTHROSCOPY

DECISION MAKING AND EFFECTIVE

ARTHROSCOPIC TECHNIQUES
IN THE MANAGEMENT OF
SHOULDER INSTABILITY (P)
Moderator: Richard L. Angelo, MD, Woodinville, WA (d - J & J, e - Mitek)

This AANA sponsored symposium provides a comprehensive discussion of the arthroscopic

management of shoulder instability. It focuses on two critical elements necessary for
achieving optimal outcomes: pre and intra-operative decision-making keys and the details
of effective arthroscopic techniques.

I. Arthroscopic Bankart Repair for Unidirectional Anterior Instability

Richard L. Angelo, MD, Woodinville, WA (d - J & J, e - Mitek)

II. Arthroscopic Management of Multidirectional and Posterior Instability

Felix H. Savoie, III, MD Jackson, MS (n)

III. Glenohumeral Bone Defects in the Management of Shoulder Instability

Stephen S. Burkhart, MD San Antonio, TX (c, e - Arthrex, Inc.)

IV. Special Situations

Richard K.N. Ryu, MD, Santa Barbara, CA (n)

V. Potential Complications Related to Arthroscopic Instability Repair

George Lajtai, MD, Althofen, Austria (c, e - Karl Storz)

VI. Case Presentations

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
244 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 245

ARTHROSCOPIC BANKART REPAIR FOR UNIDIRECTIONAL

SYMPOSIA SPORTS/ARTHROSCOPY
ANTERIOR INSTABILITY
Richard L. Angelo, MD

DECISION-MAKING FOR ARTHROSCOPIC BANKART • identify HAGL (Humeral Avulsion of Glenohumeral

REPAIR Ligaments) - AS vs OS depending on pathology extent
and surgeon experience
1. Patient Goals – How to Define Success
• Hill-Sachs lesion – if large (>25%) or “engaging”, per-
• must individualize; ??? only eliminate recurrent disloca-
form OS (some loss of ER may be important aspect of
tion / apprehension or return to normal function and
limiting recurrence
quality of life
• labral tears – look for associated SLAP lesions
• throwing, overhead athletes/workers – better chance of
• partial cuff tears; may be source of ongoing Sx and
return to high level function with arthroscopic stabiliza-
require debridement
tion (AS)
• contact/collision, heavy laboring activities – studies TECHNIQUE: SUTURE ANCHOR ARTHROSCOPIC
results mixed - depends a great deal on capsulolabral BANKART REPAIR
quality / integrity ; not an absolute contra-indication
1: optimize visualization
2. Surgeon Experience • mildly hypotensive anesthesia (systolic approx.
• we must critically asses our own skill development and 90mmhg)
decide on our ability to address each component of the • epinephrine in the irrigant (1 amp1/100,000 epi/3L)
instability pathology • fluid pump vs adequate gravity
• requires study, thorough planning, rehearsal with OR
2: positioning (must be sufficient to access all pathology)
staff
• lateral decubitus: 5-10# distal “suspension” - excessive
3. History trxn may compromise ability to retention IGHL
• patient age: higher RR if < 20-22 yo whether open stabi- — accessory lateral traction (5-10#) – perpendicular to
lization (OS) or AS; age not an absolute contra-indica- humeral shaft
tion to AS - depends on capsulolabral quality / tissue — arm @ 25o abduction, 15o flexion
elasticity • beachchair position
• as # instability episodes goes up, recurrent rate increases — easier to convert to open procedure
likely due to increased capsular strain / attenuation, — access to posterior aspect of joint much more difficult
labral tearing, glenoid erosion
3: portals
4. Physical Examination (must confirm clinical impression) • Posterior (P): 1.5cm inferior, 1.0 cm medial to postero-
• excessive anterior / inferior translation is present; must lateral acromial tip - direct anteromedially toward tip of
also determine posterior and inferior laxity coracoid
• ROM: greater than normal range, esp. ER suggests signifi- • Anterosuperior (AS): use spinal needle to establish path;
cant capsular laxity enter skin 1cm lateral and slightly anterior to anterolater-
• + apprehension in AB/ER al acromial tip; direct cannual immediately anterior to
• + relocation test biceps
• + Sulcus Sign – determine if it corrects @ 200 ER (if so, • Midanterior (MA): 1 ½ cm lateral, 1 ½ cm inferior to
coracohumeral ligament is likely competent) inferolateral coracoid tip - direct cannula immediately
• hyperelasticity tests (thumbs, elbows, patellas) – if superior to superior subscap boarder - approach glenoid
“hyperelastic / pathologic collagen”, consider open ante- @ 30 - 450 angle to glenoid rim in transverse plane; 8.5
rior capsular shift mm clear, threaded cannula over switching stick works
well (verify access to anterior / inferior glenoid)
5. Studies
• X-ray: AP, West Point, Stryker notch – evaluate Hill-Sachs 4: glenoid preparation
defect • debridement of articular cartilage margins (turn suction
• ArthroCT, MRI – evaluate size of glenoid rim defect / size off off shaver)
of fracture fragment • liberator / elevator - essential to complete inferior capsu-
lolabral release around to 6:30
6. Dx Arthroscopy
• medial release along glenoid neck must be adequate to
• Bankart lesion; capsular margin may be difficult to iden-
free/mobilize capsule (subscap muscle should be visible)
tify if no labrum remaining; look for ALPSA (anterior
• light excoriation of anterior glenoid neck with shaver /
labral periosteal sleeve avulsion)
burr
• glenoid rim fracture – identify and estimate size / mobil-
• fracture fragment:
ity
— if < 15%: excise by running burr in reverse with suc-
• glenoid erosion; if > 25% using "bare spot" central refer-
tion off
ence, recommend coracoid or iliac crest bone graft
— if 15 - 25%: consider repair of fragment, capsule and
• capsule; "guesstimate" capsular strain - helps determine
labrum with encircling or petetrating suture from
how much capsular plication/shift indicated with anchor
anchor (don't overreduce)
sutures; beware capsular "rents" - may be present even
with Bankart lesion

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
245
SYM 07:Layout 1 1/12/07 11:41 AM Page 246

5: sufficient IGHL / labral complex retensioning beneath intact labrum to exit at the labrum / articular
• drill anchor hole 2-3mm onto articular surface @ 45o to cartilage margin (may need to use suture anchor if
the glenoid rim labrum deficient)
SYMPOSIA SPORTS/ARTHROSCOPY

• insert anchor, test security; avoid metal (many reliable — may consider shuttling permanent suture if desired
non-metalic anchors available) — tie sliding knot with capsular limb as post; back up
• suture delivery: (if not using a knotless anchor); many with 1/2 hitches
devices available - critical to deliver suture through cap- • if inferior translation exceeds 5 - 7 mm, close rotator
sule at least 1 cm inferior to exit of anchor to adequately interval
retention capsule superiorly: — withdraw midanterior cannula to be even with cap-
— retrieve inferior limb of anchor suture out posterior sule layer
cannula — load suture retriever/penetrator with a #1 PDS 1 cm
— use cannulated suture hook to grasp 1 cm "bite" of from end of suture; introduce through the midanteri-
capsule / labrum (to adequately plicate capsule), then or cannula, pass through MGHL from outside-in and
deliver PDS and retrieve out posterior cannula retrieve suture end with graspers through anterosupe-
— tie simple throw with PDS around inferior limb of rior portal
anchor suture and shuttle out through anterior cannu- — load the suture / retriever with the other end of the
la suture and introduce through the same mid-anterior
• tie sliding knot (limb which exits through tissue must be cannula, direct penetrator superiorly and pass through
the post limb) and back-up with 1/2 hitches; repeat steps the SGHL from outside-in and again retrieve through
to establish anchors @ 5:00, 3:30, and 2:00 o’clock on the anterosuperior portal
the glenoid (occasionally 4 anchors are used) — tie arthroscopic knot via anterosuperior portal closing
• also knotless anchors available the SGHL to MGHL; add additional sutures as neces-
sary (usually 2 or 3)
6: address secondary laxity (examine after Bankart repair)
— may function primarily as an “internal splint” during
• if posterior translation exceeds 50%, consider posterior
healing
capsular plication
— using suture hook deliver "pinch-tuck" plicating 7: test repair
suture (PDS): begin 15 mm from glenoid rim and • “palpate” repair arthroscopically
grasp approx. 7 mm of capsule, then exit • remove arm from traction and test ROM and stability
— allow capsule to fold and then deliver hook tip

REFERENCES 10. Mazzocca, AD, Brown, FM, Carreira, DS.et.al. Arthroscopic Anterior Shouler
1. Baker, C.L., Uribe, J.W., Whitman, C.: Arthroscopic evaluation of acute initial Stabilization of Collision and Contact Athletes Am J Sports Med ;2005: 52-60
anterior shoulder dislocations. Am J Sports Med 18:25-28, 1990. 11. Mishra, DK, Fanton, GS, Two-Year Outcome of Arthroscopic Bankart Repair and
2. Cole, B.J., L’Insalata J., Irrgang, J., Warner, J.J.:Comparison of arthroscopic and Electrothermal-Assisted Capsulorrhaphy for Recurrent Traumatic Anterior
open anterior shoulder stabilization. A two to six-year follow-up study. JBJS 82- Shoulder Instability, Arthroscopy, 2001,17:844-849
A:1108-1114, 2001. 12. Mohtadi, NG, Bitar, IJ, Sasyniuk, TM, et.al. Arthroscopic Versus Open Repair for
3. Fabrinani C, Milano G, Demontis A et al. Arthroscopic versus open treatment of Traumatic Anterior Shoulder Instability: A Meta-analysis. Arthroscopy:2005; 652-
Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy 658
20:456-462,2004. 13. Robinson, CM, Kelly, M., Wakefield, AE. Redislocation of the Shoulder During
4. Habermeyer, P, Bleyze,P, Rickert, M, et.al. Evolution of Lesions of the Labrum- the First Six Weeks After a Primary Anterior Dislocation: Risk Factors and Results
Ligament Complex in Post-Traumatic Anterior Shoulder Instability: A Prospective of Treatment J Bone and Joint Surg 2002; 84A: 1552-1559
Study. I Shoulder Elbow Surg 1999; 66-74 14. Ryu, RK, Open Versus Arthroscopic Stabilization for Traumatic Anterior Shoulder
5. Hart, WJ, Kelly, CP. Arthroscopic Observation of Capsulolabral Reduction After Instability Sports Med Arthroc Rev 2004; 12:90-98.
Shoulder Dislocation. J Shouler Elbow Surg: 2004; 134-137. 15. Ryu RK. Arthroscopic approach to traumatic anterior shoulder instability.
6. Ide,J, Maeda, S, Tagaki, K. Arthroscopic Bankart Repair Using Suture Anchors in Arthrscopy;19 Suppl 1:94-101,2003.
Athletes. Am J Sports Med 2004;32; 1899 – 1905 16. Sperber, A., Hamberg, P., Karlsson, J., et.al. Comparison of An Arthroscopic and
7. Itoi, E., Lee, SB, Bergland, LJ, et.al. The Effect of A Glenoid Defect on An Open Procedure for Posttraumatic Instability of the Shoulder: A Prospective,
Anteroinferior Stability of the Shoulder After Bankart Repair: A Cadaveric Study. I Randomized Multicenter Study J Shoulder Elbow Surg 2001, 10, 105 – 108
Bone Joint Surg Am 2000; 35-46. 17. Stein, D.A., Jazrawi, L., Bartolozzi, A.R.: Arthroscopic stabilization of anterior
8. Kim, SH, Ha, KI, Kim, SH: Bankart repair in traumatic anterior shoulder instabil- shoulder instability: a review of the literature. Arthroscopy 18:912-924, 2002.
ity: Open vs Arthrosocpic technique. Arthroscopy 18:755-763. 2002. 18. Sugaya, H, Moriishi, J, Kanisawa, I. Et.al., Arthroscopic Osseous Bankart Repair
9. Kim, S-H, Ha, K-I, Kim, Y-M, Arthroscopic Revision Bankart Repair: A Prospective for Chronic Recurrent Traumatic Anterior Glenohumeral Instability. J Bone Joint
Outcome Study Arthroscopy 2002; 18: 469-482 Surg (Am) 2005; 1752-1760

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
246 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 247

ARTHROSCOPIC TREATMENT OF POSTERIOR AND

SYMPOSIA SPORTS/ARTHROSCOPY
MULTIDIRECTIONAL INSTABILITY
Felix H. Savoie, III, MD

A. Instability H. Posterior Instability: Surgery Tips

1. Abnormal movement of humeral head on glenoid pro- 1. Add lateral posterior portal if anchors necessary
ducing pain and functional impairment 2. Plication stitches
2. Activity related problem a. Inferior = capsule
b. Above = capsule
B. Laxity
3. Vertical shift required
1. Normal movement of humeral head on glenoid
2. Individual variation I. MDI
3. EUA measures 1. Traumatic
2. Repetitive trauma
C. Posterior Instabilty
3. Atraumatic
1. Traumatic
a. Congenital hyperelasticity
2. Repetitive trauma
b. Collagen – vascular disease
3. Atraumatic
4. ? Voluntary J. MDI: Atraumatic
a. Voluntary → involuntary 1. Why suddenly symptomatic?
b. Attention seeking 2. RC tendonitis
D. Posterior Instability: Anatomy K. MDI: Rehab
1. PIGHL dysfunction 1. Control inflammation
a. Tears 2. Stabilize scapula
b. Stretching 3. Waist level cuff exercises
2. Rotator interval laxity 4. Progress after 1 – 3
a. Congenital L. MDI: Surgery
b. Gradual 1. Failure of adequate rehab
c. Traumatic 2. Functional impairment
E. Posterior Instability: Exam 3. Capsular shift.
1. Dropping out in flexion M.Results: Posterior
2. Load/shift 1. Bradley > 90%
a. Supine 2. MSMOC > 90%
b. Neutral and with IR/abduction
3. Cofield N. Results: MDI
a. Posterior shift does not diminish 1. Snyder: 89%
4. Scapular winging 2. Treacy: 88%
3. Neer: 61%
F. Posterior Instability: Management 4. Pancapsular plication + interval plication = 95%
1. Therapy good/excellent
a. Scapular rehabilitation
b. “Centering” exercises O. Conclusion: MDI/Posterior
1. Correct diagnosis essential
G. Posterior Instability: Surgery 2. Arthroscopy > open
1. Anatomy dependent a. ? new gold standard
2. Arthroscopy > Open 3. Scapular rehab critical
3. Work on both sides

REFERENCES 8. Gerber C, Ganz R. Clinical assessment of instability of the shoulder. J Bone

1. Fronek J, Warren RF, Bowen M. Posterior subluxation of the glenohumeral joint. Joint Surg Br 1984;66:551-556.
J Bone Joint Surg Am 1989;71:205-216. 9. Hawkins RJ, McCormick RG. Posterior shoulder instability. Orthopedics
2. Hawkins RJ, Kippert G, Johnston G. Recurrent posterior shoulder instability 1988;11:101-107.
(subluxations) of the shoulder. J Bone Joint Surg Am 1984;66:169-174. 10. Rockwood CA Jr, Matsen FA. Glenohumeral instability. In: Rockwood CA Jr,
3. Pollock RG, Bigliani LU. Recurrent posterior shoulder instability: diagnosis and Matsen FA, eds. The Shoulder. Philadelphia: WB Saunders, 1990;526-622.
treatment. Clin Orthop Rel Res 1993;291:85-96. 11. McLaughlin H. Posterior dislocation of the shoulder. J Bone Joint Surg Am
4. Schwartz E, Warren RF, O’Brien SJ, et al. Posterior shoulder instability. Orthop 1952;34:584-590.
Clin North Am 1987;18:409-419. 12. Tibone JE, Preitto C, Jobe FW, et al. Staple capsulorrhaphy for recurrent posterior
5. Tibone JE, Bradley JP. The treatment of posterior subluxations in athletes. Clin shoulder dislocation. Am J Sports Med 1987;9:135-139.
Orthop Rel Res 1993;291:124-137. 13. Bigliani LU, Kurzweil PR, Schwartzbach CC, et al. Inferior capsular shift proce-
6. Tibone JE, Ting A. Capsulorrhaphy with a staple for recurrent posterior subluxa- dure for anterior-inferior shoulder instability in athletes. Am J Sports Med
tions of the shoulder. J Bone Joint Surg Am 1990;72:999-1002. 1994;22:578-584.

7. Bell RH, Noble JS. An appreciation of posterior instability of the shoulder. Clin
Sports Med 1991;10:887-899.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
247
SYM 07:Layout 1 1/12/07 11:41 AM Page 248

14. Bigliani LU, Polllock RG, McIlveen SJ, et al. Shiftf of the posteroinferior aspect of 24. Rowe CR, Yee YBK. A posterior approach to the shoulder joint. J Bone Joint
the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Surg 1944;26:580.
Am 1955;77:1011-1020. 25. Oveson J, Nielsen S. Anterior and posterior shoulder instability. Acta Orthop
SYMPOSIA SPORTS/ARTHROSCOPY

15. Boyd HB, Sisk TD. Recurrent posterior dislocation of the shoulder. J Bone Joint Scand 1986;57:324-327.
Surg Am 1972;54:779-786. 26. Hawkins RJ, Belle RM. Posterior instability of the shoulder. Instr Course Lect
16. Bowen MK, Warren RF. Ligamentous control of shoulder stability based on 1989;38:211-215.
selective cutting and static translation experiments. Clin Sports Med 27. Hurley JA, Anderson TE, Dear W, et al. Posterior shoulder instability: surgical
1991;10:757-782. versus conservative results with evaluation of glenoid version. Am J Sports Med
17. O’Brien SJ, Neeves MC, Arnoczky SP, et al. The anatomy and histology of the 1992;20:396-400.
inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 28. Rockwood CA Jr, Burkhead WZ, Brna J. Subluxation of the glenohumeral joint:
1990;18:449-456. response to rehabilitatie exercise, traumatic vs. atraumatic instability. Orthop
18. Gibb TD, Sidles JA, Harryman DT, et al. The effect of capsular venting on gleno- Trans 1986;68:724-731.
humeral laxity. Clin Orthop Rel Res 1993;291:54-66. 29. Scott DJ. Treatment of recurrent posterior dislocations of the shoulder by gleno-
19. Warren RF, Kornblatt IB, Marchand R. Static factors affecting posterior shoulder plasty. J Bone Joint Surg Am 1967;49:471-476.
instability. Orthop Trans 1989;8:1. 30. Brewer BJ, Wubben RC, Carrera GF. Excessive retroversion of the glenoid cavity.
20. Capari RB, Beissler WB. Arthroscopi manifestations of shoulder subluxations J Bone Joint Surg Am 1986;68:724-731.
and dislocations. Clin Orthop Rel Res 1993;291:54-66. 31. Surin V, Blader S, Markhede G, et al. Rotational osteotomy of the humerus for
21. Cordasco FA, Steinnman S, Flatow FL, et al. Arthroscopic treatment of glenoid posterior instability. J Bone Joint Surg Am 1990;72:181-186.
labral tears. Am J Sports Med 1993;21:425-430. 32. Neer CS. Surgical repair for recurrent posterior instability. In: Neer CS, ed.
22. Habermeyer P, Schuller V, Weideman E. The intra-articular pressure of the shoul- Shoulder Reconstruction. Philadelphia: WB Saunders, 1990.
der: An experimental study of the role of the glenoid labrum in stabilizing the 33. Wolf EM, Eakin CL. Arthroscopic capsular placation for posterior shoulder insta-
joint. Arthroscopy 1993;8:166. bility. Arthroscopy 1998;14(2):153-163.
23. Lippitt SB, Vanderhooft JE, Harris SL, et al. Glenohumeral stability from concavi-
ty-compression. A Quantitative analysis. J Shoulder Elbow Surg 1993;2:27-35.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
248 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 249

GLENOHUMERAL BONE DEFECTS IN THE MANAGEMENT OF

SYMPOSIA SPORTS/ARTHROSCOPY
SHOULDER INSTABILITY
Stephen S. Burkhart, MD

A. Considerations in the Management of Glenoid Defects glenoid rim

1. etiology 4. prepare glenoid
• traumatic rim fracture • lightly excoriate glenoid neck
• progressive erosion secondary to recurrent instability • contour coracoid to match glenoid surface
2. assessing glenoid defect size • insert 3 suture anchors along bone/cartilage junction
• identify central glenoid bare spot at center of inferior 5. secure graft
2/3 of glenoid • match coracoid graft to glenoid defect to make it
• introduce calibrated probe from posterior portal and "flush" with articular surface
measure distance from posterior glenoid rim to bare • fix with 2 transglenoid screws
spot • if slightly "proud", burr flush with glenoid
• with same probe, measure distance from bare spot to 6. complete repair (to make bone graft extra-articular)
deficient glenoid rim • repair capsule with anchor sutures
• estimate % defect of anterior glenoid • repair subscap tendon
B. Recommendations for Glenoid Defects D. Considerations in the Management of Humeral Head
Type I (0-12.5% defect) Defects
• excise fragment to shell and complete suture anchor 1. etiology
repair (avoid disruption of the capsuloperiosteal layer • prolonged dislocation
- weakens suture purchase) • recurrent dislocations
Type II (12.5 - 25% defect) 2. assessing humeral head defect size
• If "significant" fragment, consider arthroscopic reduc- • X-ray - Stryker notch view
tion, internal fixation (ARIF) • CAT scan is most accurate (with 3-D reconstructions)
— suture anchor fixation 3. assessing probable functional impact
¬ mobilize fragment, freshen / contour surfaces • creates decreased stability arc
¬ insert anchors (3 or 4) at bone / articular carti- • determine "engagement" in position of AB / ER dur-
lage junction ing EUA
¬ encircle fragment with anchor sutures, or
E. Management of Large Hill-Sachs defects
¬ drill holes through fragment from posterior or 5
If < 30% articular surface defect and no engagement of head
o'clock portal, tie in mattress fashion with
• arthroscopic Bankart repair
suture from adjacent anchor
If > 30% articular surface defect or engagement
— may consider cannulated screw fixation (access dif-
• consider open stabilization (Latarjet reconstruction)
ficult)
• +/- osteochondral graft into head defect
• If "insignificant" fragment, excise and complete suture
— deltopectoral approach, dislocate humeral head
anchor repair
— size posterior defect
• If no fragment, then suture anchor repair
— create matching graft from donor humeral head
Type III (> 25% defect) "inverted pear" configuration
— secure with countersunk / absorbable screws
• If bone fragment, consider ORIF
• arthroscopic "remplissage"
• If no fragment, consider Latarjet
— view from anterosuperior portal
C. Modified Latarjet — excoriate base of defect with burr via posterior por-
1. exposure tal
• deltopectoral approach — introduce double-loaded suture anchor/s into
• expose coracoid defect
• detach pec minor with a small fragment of bone — withdraw posterior cannula to just outside capsulo-
2. harvest coracoid tendinous layer (infraspinatus)
• osteotomize coracoid just anterior to coracoclavicular — introduce penetrator for retrograde retrieval of
ligaments sutures (pass all sutures first)
• protect musculocutaneous nerve during transfer — tie sutures outside of capsulotendinous layer
3. expose glenoid (blind); fills defect with infraspinatus tendon / cap-
• detach/reflect upper 1/2 of subscap sule
• expose inferior capsule and detach 1 cm medial to

REFERENCES 3. Walch G, Boileau P. Latarjet-Bristow procedure for recurrent anterior instability.

1. Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their relation- Tech Shoulder Elbow Surg 2000; 1: 256-261.
ship to failure of arthroscopic Bankart repairs: significance of the inverted-pear 4. Churchill RS, Moskal MJ, Lippett SB, Matsen FA III. Extracapsular anatomically
glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000; 16(7): contoured anterior glenoid bone grafting for complex glenohumeral instability.
677-694. Tech Shoulder Elbow Surg 2001; 2: 210-218.
2. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for
the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;
80(6): 841-852.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
249
SYM 07:Layout 1 1/12/07 11:41 AM Page 250

.MANAGEMENT OF THE FIRST-TIME ANTERIOR

SYMPOSIA SPORTS/ARTHROSCOPY

SHOULDER DISLOCATION
Richard K.N. Ryu MD

1. Anatomy b. Both entities can lead to further tissue damage with

a. Stability recurrent episodes
i. Dynamic (muscular); Static (labrum, IGHL, convexi- c. Quality of life indicators appear to justify stabilization
ty)
7. Conclusions
2. Pathology at initial dislocation a. Highly selective for consideration of early surgical inter-
a. Bankart lesion most common vention
b. Hill-Sachs >60% i. High risk→ contact athlete, adolescent, lig laxity
c. Capsular tearing, SLAP, PRCT less often b. Rationale similar to ACL and recurrence:
3. Natural History i. Quality of life, progressive tissue damage
a. “Pseudo” meta-analysis of recurrence rates ( ranging 17% c. Requires in-depth discussion of multiple variables
to 90%) between surgeon and HIGH RISK patient regarding
i. Overall mean 67% intrinsic risk factors
ii. Recent data with 25 year follow-up MICROINSTABILITY AND THE THROWING ATHLETE
1. Hovelius 2006 (AAOS) less than 50% recurrence →
1. Possible etiologies:
115 of 227 patients without recurrence over 25
a. Athlete with generalized ligamentous laxity participating
years
in repetitive overhead sport
iii.Special groups with higher risk:
i. Capsular compromise leads to instability; usually
1. Contact/collision athletes
anterior-inferior
2. Adolescent population
ii. Usually associated with secondary rotator cuff pathol-
3. Significant bone loss
ogy
4. Generalized ligamentous laxity
iii.Scapulothoracic dysfunction can place anterior cap-
4. Progressive soft tissue injury with recurrences sule at risk
a. Habermeyer → increased bone and soft tissue damage iv. Treatment → initial rehabilitation focusing on core
correlated to number of instability episodes and scapulothoracic; if unsuccessful, capsular plica-
b. Urayama → MR evidence of capsular elongation with tion indicated
recurrences b. Pseudolaxity associated with SLAP lesion
i. Obligate anterior-inferior instability e.g. positive drive-
5. Treatment Options: through sign without capsular compromise
a. Immobilization and rehabilitation ii. Once SLAP is repaired, laxity is corrected as well
i. External rotation with very low recurrence rate iii.Treatment consists of SLAP repair; if pseudolaxity not
b. Surgical stabilization corrected, plication of anterior capsule in conjunction
i. Technique with SLAP repair
1. Open vs. arthroscopic; success rates converging;may c. G.I.R.D. Syndrome with internal impingement
reflect effort to preserve external rotation in the ath- i. G.I.R.D. + Posterior-superior Type II SLAP: gleno-
lete humeral internal rotation deficit (GIRD) leads to HH
2. Arthroscopic: recurrence rate between 5-10%(cur- shifting posterior and superior; hyperexternal rotation
rent)
occurs → peel-back of post-superior labrum results;
c. Prospective studies
anterior capsular stretching can occur late → internal
1. Kirkley → arthroscopic results superior to conservative
impingement forces
2. Bottoni /DeBernardino→ Operative far better recur- ii. Treatment:( if rehabilitation unsuccessful)
rence rate compared to non-operative 1. Capsular insufficiency: anterior stabilization
3. Larain → much higher recurrence rate in non-op 2. G.I.R.D. + Posterior-superior Type II: Fix SLAP; usu-
rugby ally the anterior subluxation is corrected with SLAP
6. Are first-time anterior shoulder dislocations analogous to repair; if not, limited thermal or capsular tucks.
the torn ACL in the HIGH RISK population? Consider posterior capsular release if internal rota-
a. Both can be associated with disabling functional loss tion deficit severe

REFERENCES 4. Ryu, R. Arthroscopic Approach to Traumatic Anterior Shoulder Instability

1. Hovelius, L., Skoglund, U, Sandstrom, B., Prognosis of First-Time Shoulder Arthroscopy, 2003 (supplement), 19: 94-101
Dislocation in the Young. Presented at AAOS 73rd Meeting. March 22-26, 2006. 5. Ide,J, Maeda, S, Tagaki, K. Arthroscopic Bankart Repair Using Suture Anchors in
Chicago, Illinois Athletes. Am J Sports Med 2004;32; 1899 – 1905
2. Ryu, RKN, Dunbar, W.H., Kuhn, J.E., et.al. Comprehensive Evaluation and 6. Habermeyer, P, Bleyze,P, Rickert, M, et.al. Evolution of Lesions of the Labrum-
Treatment of the Shoulder in the Throwing Athlete. Arthroscopy Vol.18 (supple- Ligament Complex in Post-Traumatic Anterior Shoulder Instability: A Prospective
ment), 70-89, 2002 Study. I Shoulder Elbow Surg 1999; 66-74.
3. Mazzocca, AD, Brown, FM, Carreira, DS.et.al. Arthroscopic Anterior Shoulder 7. Itoi, E., Hatakayama, Y, Kido, T., et.al., A New Method of Immobilization After
Stabilization of Collision and Contact Athletes Am J Sports Med ;2005: 52-60 Traumatic Anterior Dislocation of the Shoulder: A Preliminary Study. J Shoulder
Elbow Surg 2003; 12: 413-415

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
250 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 251

8. Barber, F.A., Ryu, RK., Tauro, JC., Point-Counterpoint: Should First Time Anterior 13. Kirkley A, Griffen S, Richards,C. et al., Prospective Randomized Clinical Trial
Shoulder Dislocations Be Surgically Stabilized? Arthroscopy 2003, 19; 305-309 Comparing the Effectiveness of Immediate Arthroscopic Stabilization Versus
9. Burkhart, SS, De Beer, JF, Traumatic Glenohumeral Bone Defects and Their Immobilization and Rehabilitation in First Traumatic Anterior Dislocations of

SYMPOSIA SPORTS/ARTHROSCOPY
Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the the Shoulder. Arthroscopy, 1999, 15:507-514.
Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion, Arthroscopy, 14. Baker CL Arthroscopic Evaluation of Acute Initial Shoulder Dislocations, in
2000, 16:677-694. Pritchard DJ (ed): Instr Course Lect, AAOS 1996, Vol 45,, 83-89.
10. Pagnani,MJ, Dome, DC, Surgical Treatment of Traumatic Anterior Shoulder 15. Burkhart, S.S., Morgan, C.D., Kibler, W.B., Current Concepts: The Disabled
Instability in American Football Players JBJS 2002, 84:711-715 Throwing Shoulder: Specturm of Pathology Part I: Pathoanatomy and
11. Magnusson, L., Kartus, J., Ejerhed, L., et.al. Revisiting the Open Bankart Biomechanics, Arthroscopy Vol.19, 404-420, 2003
Experience Am J Sports Med 2002, Vol.30, 778-782 16. Davidson PA, Elattrache NS, Jobe CM, et al : Rotator cuff and posterior-superior
12. Bottoni, CR, DeBernardino, TM, et al., A Prospective Randomized Evaluation of glenoid labrum injury associated with increased glenohumeral motion: A new
Arthroscopic Stabilization Versus Nonoperative Treatment of Acute, Traumatic, site of impingement. J Shoulder Elbow Surg 4:384-390, 1995
First-Time Shoulder Dislocation. Arthroscopy (abs), 2000, 16, 432 17. Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the
supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study.
J Shoulder Elbow Surg 1:238-245, 1992

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
251
SYM 07:Layout 1 1/12/07 11:41 AM Page 252

POTENTIAL COMPLICATIONS RELATED TO ARTHROSCOPIC

SYMPOSIA SPORTS/ARTHROSCOPY

INSTABILITY REPAIR
Georg Lajtai, MD

A. Patient Selection • "proud anchor" - may excoriate humeral articular car-

1. laxity vs. true "instability" tilage
• careful history 4. inadequate capsular retentioning
• accurate physical exam • undesireable suture placement
• supportive imaging studies 5. suture management
• confirmation with EUA • difficult passage / manipulation of sutures
2. incorrect diagnosis 6. suture fixation security
• cervical radiculopathy • knot slippage
3. failure to appreciate all instability pathology • insufficient loop security
• rotator interval pathology
C. Neurologic
• ALPSA
1. traction neuropraxia
• HAGL
• transient paresthesias
B. Technical Errors 2. cervical radiculopathy
1. patient positioning • neck positioning
• distorted orientation
D. Misc
• poor access
1. fluid extravasation
2. portal placement
• distortion of anatomy
• impailing / scuffing articular cartilage with trocars
• dysfunctional portals
• inability to instrument specific regions of the shoulder
• tracheal pressure
• inaccurate approach to the glenoid resulting in dam-
age to articular surfaces E. Rehabilitation
3. poor anchor placement 1. insufficient protection
• risk damage to articular cartilage if approach "shal- • insufficient repair healing with recurrent instability
low" 2. tardy mobilization
• excessively medial anchor placement / fixation • loss of motion / adhesions
• anchor not secure - may loosen

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
252 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 253

SYMPOSIA SPORTS/ARTHROSCOPY
EVIDENCE BASED DECISION MAKING IN
SPORTS MEDICINE (Y)
Moderator: Rick W. Wright, MD, Saint Louis, MO (n)

A systematic approach to literature review allows clinicians to use evidence based medicine
as a platform for clinical decision making. This symposium will review studies in sports
medicine of sufficient scientific merit to influence physician’s clinical decisions in the areas
of shoulder, foot and ankle and knee.

I. Introduction to Evidence Based Medicine and its Role in Clinical Decision Making
Rick W. Wright, MD, Saint Louis, MO (n)

II. Foot and Ankle Injury Decision Making in Sports Medicine

Ammimziato Amendola, MD, Iowa City, IA (a)

III. Answering Controversy in the Treatment of Shoulder Conditions

John E. Kuhn, MD, Nashville, TN (a, b – Arthrex)

IV. Clinical Decision Making for Knee Injuries in Sports

Kent P. Spindler, MD, Nashville, TN (a – Smith & Nephew, Aircast)

V. Discussion

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
253
SYM 07:Layout 1 1/12/07 11:41 AM Page 254

FOOT AND ANKLE INJURIES

SYMPOSIA SPORTS/ARTHROSCOPY

Annunziato Amendola, MD

Introduction 3. THE USE OF NON-STEROIDAL ANTI-INFLAMMATORY

The entities to be discussed will include the following: (NSAIDS) MEDICATION IN THE TREATMENT OF ACUTE
1. Acute treatment of Achilles tendon tears ANKLE SPRAINS
2. Treatment of high ankle sprains The objective of this portion of the paper was to assess the
3. Mobilization vs. immobilization following an acute effect of NSAIDS in the treatment of acute ankle sprains by
ankle sprain looking at the following:
4. Use of NSAIDS with acute ankle sprains a. Pain relief.
5. Anatomic vs. nonanatomic reconstruction for chronic b. Return to activity.
ankle instability c. Adverse effects from the use of the medication.
In each of these sections, a similar format was used in obtain-
Discussion
ing, analyzing and presenting the data.
In summary, when looking at the use of non-steroidal anti-
TOPICS inflammatory medication in this patient population with ankle
sprains there does seem to be a statistically significant effect in
1. Syndesmotic Sprains
terms of pain relief and return to activity. Return to activity is
The specific objectives are the following:
improved with the use of non-steroidal anti-inflammatory med-
a. Assess if there are any specific diagnostic methods or
ication. However, it appears that the number of reported
strategies
adverse events is greater with the use of medication versus place-
b. The severity of injury through the time lost from sport
bo. As with the previous reviews there are significant problems
and time to return to play.
with many of these studies in that differing reporting systems,
c. Identify any treatment modalities administered specifi-
outcome scores, and reporting of adverse events were utilized.
cally for this condition.
In addition, select medications were used and very few head to
d. To make conclusions based on the strength of the evi-
head comparisons are available.
dence supporting the diagnostic and treatment strategies
employed for this condition.
4. Acute Treatment of Lateral ankle Sprains: immobilization
Discussion: vs. Functional Rx
Syndesmotic or high ankle sprains continue to be a common The objective of this systematic review was to compare
injury that results in significant time lost from sport. It is obvi- immobilization versus mobilization with respect to the fol-
ous from the low level of evidence that is available in the litera- lowing:
ture regarding this topic yields a significant amount of relative- a. Return to sport or work/ activity
ly soft information. The conclusion to be made from this type b. Residual subjective instability,
of evidence is that the diagnosis probably is not totally clear in c. Re-injury
assessing the severity of the injury and therefore the likelihood d. Overall patient satisfaction.
of predicting the time lost from sport. In addition, the diag-
Discussion
nostic modalities were not clear or specific. Therefore, if a spec-
The deficits in analyzing the literature are again prominent with
trum of injury has been diagnosed than there will be a spectrum
significant variation in the definition of immobilization, func-
of time lost in turn to sport.
tional treatment, and rehabilitation. Non-validated outcome
measures are widely used, i.e. patient satisfaction. Based on this
2. Achilles Tendon Tears: Open surgical treatment vs. nonop-
level of evidence it appears that functional treatment early range
erative immobilization
of motion is more effective than immobilization in terms of
The specific objectives are the following:
days it takes to return to sport or activity, residual subjective
1. Assess rerupture rate and other complications following
instability and the rate of re-injury. On the other hand, it
treatment
appears that in the small number of studies that reported over-
2. Assess return to work and sport for this condition.
all patient satisfaction, patients were satisfied with immobiliza-
3. To make conclusions based on the strength of the evi-
tion versus early mobilization.
dence supporting the treatment strategies employed for
this condition.
5. Chronic Ankle Instability: Anatomic vs. Non-Anatomic
Discussion Lateral Ankle Reconstruction
Based on this data presented (level 1 evidence), on Achilles rup- The objective of this evaluation was to assess the outcome
tures, the incidence on rerupture is significantly higher in the of anatomic ankle reconstruction (Broström) versus the
nonoperatively treated patients. Incidence of other complica- non-anatomic type reconstruction for chronic ankle insta-
tions is higher in the operatively treated group. Return to sport bility, looking in particular at the following:
or work showed no significant advantage of surgery over closed a. Outcome scales or return to activity profile,
treatment. Although this is level 1 evidence there is bias, with b. Complications
the rehabilitation protocol differing between the operative and c. Recurrent instability
nonoperative groups in all 3 studies. d. Reduction of subtalar motion (inversion and eversion).

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
254 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 255

TABLE : CHRONIC ANKLE INSTABILITY

Authors Journal Year Patients at final follow-up Mean follow-up Level of

SYMPOSIA SPORTS/ARTHROSCOPY
evidence
Hennrikus et al. American Journal of 1996 Overall – 38/40 (95%) for interview, 18/40 Overall 29 months (36 – 96 II
Sports Medicine (45%) for exam and radiography months)
Anatomic – 10/21 (48%) for exam and
radiography
Non-anatomic – 9/19 (47%) for exam and
radiography
Krips et al. Journal of Bone and 2002 Overall 99/112 (88%) Overall – not specified III
Joint Surgery Anatomic – 54/59 (92%) Anatomic – 19.9 ± 3.6 years
British Non-anatomic – 45/53 (85%) Non-anatomic 21.8 ± 4.6 years
Thermann et al. Foot & Ankle 1997 Overall – 189/244 (77%) Overall – not specified III
International Anatomic – 102/131 (78%) Non-anatomic – 7.5 years
Non-anatomic – 87/113 (77%) Anatomic – not specified

Authors Outcome measures Anatomic procedure Non-anatomic Rehabilitation protocol

procedure
Hennrikus et al. Sefton et al.* Modified Brostrum Chrisman-Snook Both groups – cast for six
weeks followed by physical
therapy
Athletic activity restricted until
18 weeks postoperatively
Krips et al. Karlsson et al. 1991 Karlsson 1989 Evans 1953 Both groups – cast for six
(100 point scale) weeks followed by physical
Good 1975 (graded therapy
scale)
Thermann et al. Zwipp & Krettek Brostrum +/- Evans 1953 Not specified
(±100 point scale) periosteal flap
reinforcement
* Excellent – full activity, including strenuous sports, with no pain, swelling or giving way of the ankle; Good – occasional aching
of the ankle but only after strenuous exercise, no giving way or felling of apprehension; Fair – residual instability and remaining
apprehension but less instability and apprehension as compared with the patient’s ankle condition before surgery; Poor – recur-
rent ankle instability and giving way, unchanged or worse in normal activities with episodes of pain and swelling

Authors Outcome Scores Residual Instability Talar tilt

Anatomic Non-anatomic Anatomic Non-anatomic Anatomic Non-anatomic
Hennrikus et al. 48% excellent (10/21) † 16% excellent (3/19) † 100% stable (21/21) 90% stable (18/20) 7 degrees 5 degrees
33% good (7/21) 68% good (13/19) 0% unstable (0/21) 10% unstable (2/20) (range 6-15) (range 0-15)
14% fair (3/21) 5% fair (1/19)
5% poor (1/21) 11% poor (2/19)
Krips et al. Karlsson Karlsson 3.3 ± 3.80** 7.9 ± 5.90**
19% excellent (10/54) 9% excellent (4/45)
54% good (29/54) 9% good (4/45)
24% fair (13/54) 47% fair (21/45)
4% poor (2/54) 36% poor (16/45)
Good Good
26% excellent (14/54) 13% excellent (6/45)
54% good (29/54) 20% good (9/45)
19% fair (10/54) 44% fair (20/45)
2% poor (1/54) 22% poor (10/45)
Thermann et al.* 87% good or excellent (89/102) 92% good or excellent (80/87) 76 % stable (78/102) 85% stable (74/87) 4.6 degrees 3.3 degrees
13% fair or poor (13/102) 8% fair or poor (7/87) 24% moderately 15% moderately
unstable (24/102) unstable (13/87)
0% unstable (0/102) 0% unstable (0/87)

†Sefton
Authors score better for anatomic
Wound Complicationsthan non-anatomic reconstruction, Anterior
Sensory loss Fisher’s exact
Talar test, P=0.043
Translation Reoperations
* No significant difference
Anatomic in any parameters,
Non-anatomic Kruska-Wallis
Anatomic H-test, Mann-Whitney
Non-anatomic Anatomic U-test (P>0.05)
Non-anatomic Anatomic Non-anatomic
**Hennrikus et al.
Significant 0/19 (0%)†
difference in5/20 (25%)†
talar 2/21(10%),
tilt, ANOVA, p<0.001
0/21 (0%)
11/20 (55%), 8/20
(40%) permanent†
permanent†
Krips et al. 3.6 ± 5.0 ± 3.1mm** 13% (7/54); 3 38% (17/45); 9
2.1mm** arthroscopies for arthroscopies for
anterior bony anterior bony
impingement, 2 impingement, 3 reefings
removal of scar of capsule for persistent
tissue, one revision of laxity, 3 partial
anatomic synovectomies for
reconstruction, one anterior soft-tissue
repair of ruptured impingement, 2
posterior tibial explorations of
tendon* neuroma*
Thermann et al.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
255
SYM 07:Layout 1 1/12/07 11:41 AM Page 256

Authors Outcome Scores Residual Instability Talar tilt

Anatomic Non-anatomic Anatomic Non-anatomic Anatomic Non-anatomic
Hennrikus et al. 48% excellent (10/21) † 16% excellent (3/19) † 100% stable (21/21) 90% stable (18/20) 7 degrees 5 degrees
SYMPOSIA SPORTS/ARTHROSCOPY

33% good (7/21) 68% good (13/19) 0% unstable (0/21) 10% unstable (2/20) (range 6-15) (range 0-15)
14% fair (3/21) 5% fair (1/19)
5% poor (1/21) 11% poor (2/19)
Krips et al. Karlsson Karlsson 3.3 ± 3.80** 7.9 ± 5.90**
19% excellent (10/54) 9% excellent (4/45)
54% good (29/54) 9% good (4/45)
24% fair (13/54) 47% fair (21/45)
4% poor (2/54) 36% poor (16/45)
Good Good
26% excellent (14/54) 13% excellent (6/45)
54% good (29/54) 20% good (9/45)
19% fair (10/54) 44% fair (20/45)
2% poor (1/54) 22% poor (10/45)
Thermann et al.* 87% good or excellent (89/102) 92% good or excellent (80/87) 76 % stable (78/102) 85% stable (74/87) 4.6 degrees 3.3 degrees
13% fair or poor (13/102) 8% fair or poor (7/87) 24% moderately 15% moderately
unstable (24/102) unstable (13/87)
0% unstable (0/102) 0% unstable (0/87)

Significant difference
† Authors Woundin total complications, Fisher’s
Complications exact test, P<0.001.
Sensory loss Anterior Talar Translation Reoperations
** Significant difference
Anatomic forNon-anatomic
anterior talarAnatomic
translation,Non-anatomic
ANOVA, p=0.007. Anatomic Non-anatomic Anatomic Non-anatomic
Hennrikus
Authors et al. 0/19 (0%)† 5/20 Changes
Degenerative (25%)† 2/21(10%), 11/20III)
Severe (Grade (55%), 8/20
Osteoarthritis Reoperation Rate
Anatomic Non-anatomic 0/21 (0%)
Anatomic(40%) permanent†
Non-anatomic
Anatomic Non-anatomic Anatomic Non-anatomic
Authors et al.
Hennrikus Degenerative Changes permanent†
Severe (Grade III) Osteoarthritis Reoperation Rate
Krips et al.
Krips et al. Anatomic
59% (32/54)** Non-anatomic
78% (35/45)** Anatomic
0% (0/54) 3.6 ±
Non-anatomic
Anatomic
9% (4/45)
13% 5.0
(7/54)* ± 3.1mm**
Non-anatomic
38% (17/45)* 13% (7/54); 3
Anatomic 38% (17/45); 9
Non-anatomic
Hennrikus et et al.
al. 2.1mm** arthroscopies for arthroscopies for
Thermann
Krips et al. 59% (32/54)** 78% (35/45)** 0% (0/54) 9% (4/45) 13% (7/54)* 38% (17/45)* anterior bony anterior bony
impingement, 2 impingement, 3 reefings
*Significant
Thermann et al.difference in reoperation rate, chi-squared, p=0.004
removal of scar of capsule for persistent
Authors
**Significant difference indorsiflexion
Limited Positive Anterior
incidence of degenerative changes,Drawer Increased inversion
chi-squared, p=0.05 tissue, one revisionSupination
of deficit3 partial
laxity,
Anatomic Non-anatomic Anatomic Non-anatomic Anatomic Non-anatomic Anatomic
anatomic Non-anatomic
synovectomies for
Authors et al.
Hennrikus Limited dorsiflexion Positive
0% (0/10)Anterior Drawer
11% (1/9) Increased inversion
10% (1/10) 0% (0/9) reconstruction, one Supination deficit
anterior soft-tissue
Krips et al. Anatomic
11% (6/54) Non-anatomic
33% (15/45) Anatomic
13% (7/54)* Non-anatomic
40% (18/45)* Anatomic Non-anatomic Anatomic Non-anatomic
repair of ruptured impingement, 2
Hennrikus et
Thermann et al.
al. 0% (0/10) 11% (1/9) 10% (1/10) 0% (0/9) posterior (4/102),
4%tibial 38% (33/87),
explorations ofavg
Krips et al. 11% (6/54) 33% (15/45) 13% (7/54)* 40% (18/45)* average 50
tendon* 7.50
neuroma*
Thermann et
Thermann et al.
al. 4% (4/102), 38% (33/87), avg
average 50 7.50

* Significant difference in anterior drawer incidence, chi-squared, p=0.002

Discussion tions, re-operations and maintains normal subtalar motion or
Based on this level of evidence it seems like the anatomic recon- anatomic function of the subtalar joint. In this section, the level
struction is comparable to the non-anatomic reconstruction in of evidence is weak because of heterogeneous reporting meth-
terms of providing stability, has reduced number of complica- ods, lack of prospective data and comparison.

REFERENCES 10. Finch WF, Zanaga P, Mickelson MM, Grochowski KJ. A double-blind comparison
1. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in of flurbiprofen with diflunisal in the treatment of acute ankle sprains and strains.
national hockey league players. Am J Sports Med 2004; 32(8): 1941-5. Curr Med Res Opin 1989;11(7):409-16.

2. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports 11. Bahamonde LA, Saavedra H. Comparison of the analgesic and anti-inflammatory
Med 1991; 19(3): 294-8. effects of diclofenac potassium versus piroxicam versus placebo in ankle sprain
patients. J Int Med Res 1990 Mar;18(2):104-11.
3. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective
evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 12. Moran M. Double-blind comparison of diclofenac potassium, ibuprofen and
2001; 29(1): 31-5. placebo in the treatment of ankle sprains. J Int Med Res 1991 Mar;19(2):121-30.

4. Taylor DC, Englehardt DL, Bassett FH, 3rd. Syndesmosis sprains of the ankle. The 13. Moran M. An observer-blind comparison of diclofenac potassium, piroxicam
influence of heterotopic ossification. Am J Sports Med 1992;20(2):146-50. and placebo in the treatment of ankle sprains. Curr Med Res Opin
1990;12(4):268-74.
5. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the
ankle. Foot Ankle 1990;10(6):325-30. 14. Andersson S, Fredin H, Lindberg H, Sanzen L, Westlin N. Ibuprofen and com-
pression bandage in the treatment of ankle sprains. Acta Orthop Scand 1983
6. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability Apr;54(2):322-5.
associated with ankle sprains: a prospective examination of an athletic popula-
tion. Foot Ankle Int 1998;19(10):653-60. 15. Dreiser RL, Riebenfeld D. A double-blind study of the efficacy of nimesulide in
the treatment of ankle sprain in comparison with placebo. Drugs 1993;46 Suppl
7. Ekman EF, Fiechtner JJ, Levy S, Fort JG. Efficacy of celecoxib versus ibuprofen in 1:183-6.:183-6.
the treatment of acute pain: a multicenter, double blind, randomized controlled
trial in acute ankle sprain. Am J Orthop 2002 Aug; 31(8): 445-51. 16. Aghababian RV. Comparison of diflunisal and acetaminophen with codeine in
the management of grade 2 ankle sprain. Clin Ther 1986;8(5):520-6.
8. Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of piroxicam in
the management of acute ankle sprain in Australian Regular Army recruits. The 17. Dupont M, Beliveau P, Theriault G. The efficacy of antiinflammatory medication
Kapooka Ankle Sprain Study. Am J Sports Med 1997 Jul;25(4):544-53. in the treatment of the acutely sprained ankle. Am J Sports Med. 1987;15(1):41-
5.
9. Petrella R, Ekman EF, Schuller R, Fort JG. Efficacy of celecoxib, a COX-2-specific
inhibitor, and naproxen in the management of acute ankle sprain: results of a dou- 18. Fredberg U, Hansen PA, Skinhoj A. Ibuprofen in the treatment of acute ankle
bleblind, randomized controlled trial. Clin J Sport Med 2004 Jul;14(4):225-31. joint injuries. A double-blind study. Am J Sports Med. 1989;17(4):564-6.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
256 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 257

AN EBM APPROACH TO THE SHOULDER

SYMPOSIA SPORTS/ARTHROSCOPY
John E. Kuhn, MD

I. Evidence Based Medicine-The Value of Systematic Reviews i. Open 0-12%

ii. Arthroscopic 0-23%
II. Methods of a Systematic Review
iii.P>0.6)
a. Systematic Search for manuscripts
f. Conclusions: Current data suggests recurrence rates are
b. Systematic review of each manuscript (Spindler 2005)
similar. It is justifiable to change techniques.
c. Data in Table format and summarized
VI. Should we do arthroscopic or open repairs in the colli-
III. Should we use corticosteroids to treat rotator cuff dis-
sion athlete?
ease?
a. Systematic Review
a. Example of using EBM approach to question dogma
i. No Level 1 or 2 Studies
b. 85% of responders at AOA informal survey felt cortisone
ii. Two Level 3 Studies (Roberts 1999, Rhee 2006)
injections were beneficial for treating rotator cuff tendi-
iii.Five Level 4 Studies (Bacilla 1999, Mazzocca 2005,
nosis
Pagnani 2002, Uhorchak 2000).
c. Systematic review identified nine RCT’s (Adebajo 1990,
iv. Data is weak-Conclusions are weak!
Akgun 2004, Alvarez 2005, Berry 1980, Blair 1996,
b. Results Recurrence:
McInerney 2003, Petri 1987, Vecchio 1993, Wirthington
i. Level 3 studies
1985)
1. Roberts
d. Results for Pain (Table 1).
a. 44% Open
i. Half of studies-no significant effect
b. 62% Arthroscopic
ii. Other half, effect size was clinically significant in only
c. FLAWED! Return to Play Very different!
one study.
2. Rhee
e. Results for Motion (Table 2)
a. 12.5% Open
i. Half of studies-no significant effect
b. 25% Arthroscopic
ii. Other studies: 2/3 showed clinically significant effect
c. FLAWED! Sugical Techniques varied mid study,
f. Conclusion: Level-1 evidence suggests corticosteroids
Nonrandom allocation to groups introduces
may help with ROM, but evidence is not great, pain relief
bias.
is not supported by evidence.
ii. Level 4 studies
IV. How should we approach the patient with his/her first 1. Arthroscopic Recurrence: 7.5% to 11%
dislocation? 2. Open Recurrence: 3% to 23%
a. Example of using EBM to develop approach c. Conclusions: Current data is inadequate to answer ques-
b. Outcome: Risk of Recurrence tion. The highest levels are severely flawed, yet suggest
c. Arthroscopic surgery vs rehabilitation open may be better….
d. Systematic review identified three RCT: (Bottoni 2002, d. Caveats: Level 3 studies full of biases
Kirkley 1999, Wintzell 1999) i. Groups different
e. Results for Recurrence: 1. Return to play (risk for recurrence) differences
i. Nonoperative Treatment: 47-56% (Roberts 1999)
ii. Arthroscopic Treatment: 10-20% 2. Pathology directs treatment differences (Rhee 2006
f. Conclusion: Level-1 evidence suggests arthroscopic sur- 3. Features that predict recurrence must be equally
gery will significantly (statistically and clinically) reduce distributed!
recurrance after primary shoulder dislocation.
VII. Summary
g. Caveats: Only ~50% of those treated nonoperatively had
a. EBM Approach uses the best available evidence
recurrence. Of those with recurrence <40% decide to
b. EBM can change dogma-Cortisone may not be of much
have surgery later. Clearly doing all patients would be
benefit in rotator cuff tendinosis!
unnecessary in many. We need data on risks for recur-
c. EBM can help change approach to patients – Recurrence
rence!
is significantly less with arthroscopic surgery than non-
V. Do arthroscopic Bankart repairs have similar results to operative treatment
open repairs? d. EBM can tell us when it is time to bring new technology
a. Using EMB to decide if it is time to change your practice! into the practice: Level 1 evidence suggests arthroscopic
b. Systematic Review: Three prospective RCT (Fabbriciani results are similar to open
2004, Jorgensen 1999, Sperber 2001) e. EBM can tell us when we need better data- Open versus
c. Sample size small (41-60 subjects) arthrosocpic approach for contact athlete is not clear yet.
d. Follow up 100%
e. Recurrence Rates

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
257
SYM 07:Layout 1 1/12/07 11:41 AM Page 258

TABLE 1: REPORTED DIFFERENCES IN PAIN SCORES FOR

COMPARING CONTROLS TO SUBACROMIAL CORTICOSTEROID TABLE 2: REPORTED DIFFERENCES IN RANGE OF MOTION
INJECTION FOR ROTATOR CUFF TENDINOSIS. COMPARING CONTROLS TO SUBACROMIAL CORTICOSTEROID
SYMPOSIA SPORTS/ARTHROSCOPY

Measured Changes versus Control Group

INJECTION FOR ROTATOR CUFF TENDINOSIS.
Outcome Difference P value Statistical Clinical Measured Changes versus Control Group
Signif Signif Outcome Difference P value Clinical
Adebajo VAS 36mm <0.001 Yes Yes (degrees)* Signif
Akgun* VAS 12mm <0.001 Yes No Adebajo Active abduction +45 <0.01 Yes
Alvarez NR Akgun NR
Berry# VAS 4.6mm >0.05 No No Alvarez Active forward elevation -4.7 .49 No
Blair^ Pain scale (0-4) 0.32 (8%) <0.05 Yes No Berry Active abduction -20.2 NR No
McInerney VAS 0mm 0.99 No No Blair Active forward elevation +14 <0.0005 No
Petri^ Pain scale (0-5) 0.52 (10%) <0.01 Yes No McInerney Active abduction -1.4 0.8 No
Vecchio VAS 0mm 0.96 No No Petri Active abduction +28 0.002 Yes
Withrington VAS 15.6mm >0.05 No No Vecchio Active abduction 0 0.82 No
Withrington NR
*Pain reported at night. Follow-up at 1 month, no differences reported at 3 months.
* “+” denotes improvement in injection group as compared to control.
#Patients in control group reported less pain than injection group.
NR= not reported
^Scales are not validated. Clinical significance determined by relative weighting ver-
sus VAS on percentage basis (>30%).
VAS= Visual Analog Scale (100mm scale).
N/A= not applicable
VAS of 30mm accepted as minimal clinical difference (ref)
NR= Not reported

REFERENCES 11. Mazzocca AD, Brown FM, Jr., Carreira DS et al.: Arthroscopic anterior shoulder
1. Adebajo AO, Nash P, and Hazleman BL: A prospective double blind dummy stabilization of collision and contact athletes. Am J Sports Med, 33(1): 52-60,
placebo controlled study comparing triamcinolone hexacetonide injection with 2005.
oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. J Rheumatol, 12. McInerney JJ, Dias J, Durham S, and Evans A: Randomised controlled trial of sin-
17(9): 1207-10, 1990. gle, subacromial injection of methylprednisolone in patients with persistent,
2. Akgun K, Birtane M, and Akarirmak U: Is local subacromial corticosteroid injec- post-traumatic impingment of the shoulder. Emerg Med J, 20(3): 218-21, 2003.
tion beneficial in subacromial impingement syndrome? Clin Rheumatol, 23(6): 13. Pagnani MJ and Dome DC: Surgical treatment of traumatic anterior shoulder
496-500, 2004. instability in american football players. J Bone Joint Surg Am, 84-A(5): 711-5,
3. Alvarez CM, Litchfield R, Jackowski D et al.: A prospective, double-blind, ran- 2002.
domized clinical trial comparing subacromial injection of betamethasone and 14. Petri M, Dobrow R, Neiman R et al.: Randomized, double-blind, placebo-con-
xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med, trolled study of the treatment of the painful shoulder. Arthritis Rheum, 30(9):
33(2): 255-62, 2005. 1040-5, 1987.
4. Bacilla P, Field LD, and Savoie FH, 3rd: Arthroscopic Bankart repair in a high 15. Rhee YG, Ha JH, Cho NS Anterior shoulder stabilization in collision athletes:
demand patient population. Arthroscopy, 13(1): 51-60, 1997. Arthroscopic versus open Bankart repair. Am J Sports Med 43(6):979-985, 2006.
5. Berry H, Fernandes L, Bloom B et al.: Clinical study comparing acupuncture, 16. Roberts SN, Taylor DE, Brown JN et al.: Open and arthroscopic techniques for
physiotherapy, injection and oral anti-inflammatory therapy in shoulder-cuff the treatment of traumatic anterior shoulder instability in Australian rules foot-
lesions. Curr Med Res Opin, 7(2): 121-6, 1980. ball players. J Shoulder Elbow Surg, 8(5): 403-9, 1999.
6. Blair B, Rokito AS, Cuomo F et al.: Efficacy of injections of corticosteroids for 17. Sperber A, Hamberg P, Karlsson J et al.: Comparison of an arthroscopic and an
subacromial impingement syndrome. J Bone Joint Surg Am, 78(11): 1685-9, open procedure for posttraumatic instability of the shoulder: a prospective, ran-
1996 domized multicenter study. J Shoulder Elbow Surg, 10(2): 105-8, 2001.
7. Bottoni CR, Wilckens JH, DeBerardino TM et al.: A prospective, randomized eval- 18. Spindler KP, Kuhn JE, Dunn W, Matthews CE, Harrell FE, Dittus RS. Reviewing
uation of arthroscopic stabilization versus nonoperative treatment in patients the Orthopaedic Literature: A Systematic, Evidence Based Medicine Approach.
with acute, traumatic, first-time shoulder dislocations. Am J Sports Med, 30(4): Journal of the American Academy of Orthopaedic Surgeons 13:220-229, 2005
576-80, 2002. 19. Uhorchak JM, Arciero RA, Huggard D, and Taylor DC: Recurrent shoulder insta-
8. Fabbriciani C, Milano G, Demontis A et al.: Arthroscopic versus open treatment bility after open reconstruction in athletes involved in collision and contact
of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy, sports. Am J Sports Med, 28(6): 794-9, 2000.
20(5): 456-62, 2004. 20. Vecchio PC, Hazleman BL, and King RH: A double-blind trial comparing sub-
9. Jorgensen U, Svend-Hansen H, Bak K, and Pedersen I: Recurrent post-traumatic acromial methylprednisolone and lignocaine in acute rotator cuff tendinitis. Br J
anterior shoulder dislocation--open versus arthroscopic repair. Knee Surg Sports Rheumatol, 32(8): 743-5, 1993.
Traumatol Arthrosc, 7(2): 118-24, 1999 21. Withrington RH, Girgis FL, and Seifert MH: A placebo-controlled trial of steroid
10. Kirkley A, Griffin S, Richards C et al.: Prospective randomized clinical trial com- injections in the treatment of supraspinatus tendonitis. Scand J Rheumatol,
paring the effectiveness of immediate arthroscopic stabilization versus immobi- 14(1): 76-8, 1985
lization and rehabilitation in first traumatic anterior dislocations of the shoulder. 22. Wintzell G, Haglund-Akerlind Y, Nowak J, and Larsson S: Arthroscopic lavage
Arthroscopy, 15(5): 507-14, 1999. compared with nonoperative treatment for traumatic primary anterior shoulder
dislocation: a 2-year follow-up of a prospective randomized study. J Shoulder
Elbow Surg, 8(5): 399-402, 1999.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
258 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 259

CLINICAL DECISION MAKING FOR KNEE INJURIES IN SPORTS

SYMPOSIA SPORTS/ARTHROSCOPY
Kent P. Spindler, MD

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
259
SYM 07:Layout 1 1/12/07 11:41 AM Page 260

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
260 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 261

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
261
SYM 07:Layout 1 1/12/07 11:41 AM Page 262

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
262 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 263

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
263
SYM 07:Layout 1 1/12/07 11:41 AM Page 264

SYMPOSIA SPORTS/ARTHROSCOPY

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
264 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 265

SPONDYLOLISTHESIS: CURRENT
KNOWLEDGE AND TREATMENT OPTIONS (B)

SYMPOSIA SPINE
Moderator: J. Abbott Byrd, III, MD, Virginia Beach, VA (b, c – Biomet Spine)

It is the purpose of this symposium to explore the various types of spondylolisthesis and to
present the latest in both non-operative and operative treatment options for patients with
this problem.

I. Pathogenesis and Classification

Sigurd H. Berven MD, San Francisco, CA (a, e - DePuy Spine, Medtronic, Kyphon)

II. Evaluation and Treatment of the Pediatric Patient With Isthmic, Lytic Spondylolisthesis
John P. Dormans MD, Philadelphia, PA (n)

III. Spondylolysis and the Adolescent Athlete

J. Abbott Byrd III, MD Virginia Beach, VA (b, c - Biomet Spine)

IV. Evaluation and Treatment of the Adult Patient With Isthmic, Lytic Spondylolisthesis
Mark Weidenbaum MD, New York, NY (b - DePuy, Medtronic, Osteotech)

V. Degenerative Spondylolisthesis
John Dimar, MD, Louisville, KY (a, c, e - Medtronic Sofamor Danek)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
265
SYM 07:Layout 1 1/12/07 11:41 AM Page 266

CLASSIFICATION AND PATHOGENESIS

Sigurd H. Berven, MD

I) Introduction Acquired
Treatment strategies for the management of spondylolisthesis • Traumatic
SYMPOSIA SPINE

demonstrate significant variability. The variability observed — Acute Fracture

reflects the spectrum of ages, etiologies, and morphologies that — Stress Fracture
present under the encatchment of the diagnosis spondylolisthe- • Post-surgery
sis. Spondylolisthesis encompasses all pathologies in which — Direct surgery
there is a forward slippage of L5 on S1. The etymology of the — Indirect surgery
work combines the Greek roots for spine (Spondylo) and for- • Pathologic
ward slippage (Olisthesis). A classification system for spondy- — Local Pathology
lolisthesis is useful to provide a framework or a taxonomy for — Systematic Pathology
comparing similar cases and conditions, and for guiding care in • Degenerative
the development of an evidence-based approach to manage- — Primary
ment. The classification of Wiltse-Newman-Macnab provides a — Secondary
useful framework for spondylolisthesis based upon etiology.
II) Anatomy of the Lumbosacral Junction
The lumbosacral junction is a transition zone which transmits the
Wiltse Classification (Newman, 1963):
load from the upper body to the pelvis and hence subjected to
I. Dysplastic (Congenital) significant stresses. The stability of the L5-S1 interval depends on
the integrity of the anterior and posterior elements. The anterior
II. Isthmic:Pars Defect allows anterior migration of vertebra
elements are the vertebral bodies and the intervertebral disc;
a. Lytic fatigue fracture
whereas the posterior elements are the zygoapophyseal joints,
b. Elongated though intact pars
lamina, transverse and spinous processes, ligaments, and the pars
c. Acute fracture of the pars interarticulatis
interarticularis which unites the superior and inferior articular
III. Degenerative processes. The intervertebral disc mainly resists compression
Intact neural arch, slippage due to segmental instability whereas facet joints are the primary restraints against shear and
rotational forces. A defect in the posterior elements may result in
IV.Traumatic
creeping of the intervertebral disc secondary to stress relaxation
Disruption of posterior elements other than the pars (facet,
and subsequently result in spondylolisthesis. The defect may
pedicle, lamina)
present as an abnormality in the facet joints, such as sagittal ori-
V. Pathologic entation, hypolasia or aplasia; or a defect in the pars interarticu-
Slippage due to primary pathology of bone. laris. Recent study has demonstrated that spondylolisthesis may
Neoplasm, Osteoporosis, Tumor, Post-laminectomy occur in the face of completely normal posterior elements.
However, the classification is limited in that it does not repre- Patients with dysplastic, high-grade spondylolisthesis may have
sent the clinical or morphologic severity of the condition. Any dystrophic changes associated with the posterior elements, as
system that is intended to guide care or strategies for surgery well as anterior elements. The dystrophic changes observed in
must include a consideration of severity. The classification of the posterior elements include bifid posterior arch, pars defect,
Marchetti and Bartolozzi has utility in encompassing a broader subluxation or malorientation of the facet joints. The dystroph-
spectrum of etiologies of spondylolisthesis, and in including a ic changes that are observed in the anterior elements include
measure of the morphologic severity. Developmental spondy- bony spurs either at the posterosuperior corner of sacrum or
lolisthesis encompasses all forms that involve a morphologic posteroinferior corner of L5 vertebral body, and rounding of the
anomaly, or dysplasia, of the posterior bone elements of the sacral dome which is the most common change.
supradjacent vertebra, and the facet and endplate of the subja-
cent vertebra. High dysplastic developmental spondylolisthesis III) Radiographic Measurements
is characterized by the presence of translation of the supradja- Several radiographic parameters have been defined to evaluate
cent vertebra of the subjacent, and importantly the presence of the lumbosacral morphology. During et al defined the Pelvi-
angulation, or rotation. The pars interarticularis may be intact sacral angle (PSA) which represents the angle between a line
and elongated, or lytic. tangent to the sacral endplate and the line passing through the
center of the sacral endplate and center of the hip joints.
Classfication of Marchetti and Bartolozzi: (During, 1985) Later, Duval-Beaupere described the Pelvic
Incidence (PI) which was the angle between a line that is verti-
Developmental
cal to the sacral endplate and the line passing through the cen-
• High Dysplastic
ter of the sacral endplate and the center of the hip joints. If the
— With Lysis
hip joints are not superposed on the lateral radiogram, then a
— With Elongation
line connecting the centers of two hip joints was drawn and its
• Low Dysplastic
midpoint is accepted as the center of the hip joint. The pelvic
— With Lysis
incidence is the complementary angle of the Pelvi-sacral angle,
— With elongation
and is a constant regardless of pelvic tilt or hip flexion. Jackson
et al suggested the pelvic-radius angle (PRA) which is the angle

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
266 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 267

between a line that connects the center of hip joints and the cen-
ter of S1 upper endplate and the line that is tangential to the
upper endplate of S1. Pelvic Incidence is the one that received
general acceptance. It is constant throughout childhood and
then increases during adolescence and does not change during
adulthood. The normal value for PI in adults ranges from 47.40
to 53.10. All three parameters define pelvic morphology. Their
values are not affected by the position of the pelvis or posture;
whereas, parameters such as sacral slope and pelvic tilt are
affected by the posture. Sacral slope is defined by the angle

SYMPOSIA SPINE
between the line tangential to the sacral endplate and the hori-
zontal reference line. Pelvic tilt is the angle between a line con-
necting the center of hip joints and the center of sacral endplate
and the vertical reference line. They describe the orientation of
the pelvis rather than the morphology of it. Pelvic Incidence is Figure 2 Slip Angle
the sum of these two angles (Figure 1); therefore its value can
reflect the sagittal lumbosacral alignment. Such as, the greater IV) Pathogenesis of Spondylolisthesis:
the PI, greater has to be the SS or PT or both. As the PI increas- • Epidemiology
es the shear forces across the L5-S1 junction also increase, as — Fredrickson:
may the likelihood of development of spondylolisthesis and/or 4.4% age 6
progression of the disease. Indeed, the PI is higher in patients 6% in adulthood
with either low grade or high grade spondylolisthesis when • Genetic Factors:
compared to the normal subjects. Pelvic incidence can also help — Heretability:
to predict with regional as well as global sagittal alignment. As ¬ 29-67% incidence in first degree relatives of affected
the PI and SS increase the lumbar lordosis also increase to com- proband
pensate for the forward tilt of the trunk. Thoracic kyphosis also ¬ Spina Bifida Occulta (posterior element defect): 92%
increases in parallel with lumbar lordosis to maintain equilibri- of patients with pars defect
um. L5 incidence is recently introduced recently to evaluate ¬ Eskimo populations, incidence up to 54%
postoperative changes. It is similar to PI, but the reference point — Gender/Race factors:
is the center of the upper endplate of L5 instead of sacrum. ¬ 2X relative risk in males vs. females
Normally, it is influenced by the changes in lumbar lordosis, ¬ White males= 6.4%
however, following surgery L5 is fused to sacrum and they ¬ Black females= 1.1%
together act as one unit. — Underlying dysplasia of Lumbosacral anatomy (see
Another parameter is the slip angle (lumbosacral angle) which anatomy section)
is the angle between a line that is tangential to the lower end- • Environmental factors:
plate of L5 and the line that is vertical to the line that is tangen- Not identified at birth, rarely seen before walking age, and not
tial to the posterior body of S1. Restoration of the slip angle seen in chronically bedridden child
rather than the percentage of slip has been advocated as an Hyperextension of the lumbar spine appears to predispose to
important goal of surgery in spondylolisthesis. spondylolysis:
¬ Hip flexion contractures
¬ Thoracic kyphosis (Scheuermann’s Disease)
¬ Athletics and recurrent stress:
¬ 47% incidence in adolescent athletes complaining of
low back pain
Prevalence in Athletes:
Diving: 63.3%
Gymnastics: 11-33%
Wrestling: 12-33%
Weight Lifting: 15-36%
Football: 15-21%
Judo: 12%

Figure 1 Parameters of pelvic morphology and alignment

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
267
SYM 07:Layout 1 1/12/07 11:41 AM Page 268

REFERENCES 11. Boulay C, Tardieu C, Hecquet J, Benaim C, Mouilleseaux B, Marty C, Prat-Pradal

1. Diab M: Lexicon of orthopaedic etymology. Harwood academic publishers. 1999 D, Legaye J, Duval-Beaupere G, Pelissier J. Sagittal alignment of spine and pelvis
regulated by pelvic incidence: standard values and prediction of lordosis.Eur
2. Wiltse L, Newman PH, MacNab I: Classification of spondylolysis and spondy- Spine J. 2006 Apr;15(4):415-22. Epub 2005 Sep 23.
lolisthesis. Clin Orthop 1976:117-123.
12. Hanson DS, Bridwell KH, Rhee JM, Lenke LG.Correlation of pelvic incidence
3. Marchetti PG, Bartolozzi P: Classification of Spondylolisthesis as a Guideline for with low- and high-grade isthmic spondylolisthesis. Spine. 2002 Sep
Treatment. In The Textbook of Spinal Surgery. Second Edition. Edited by Keith H. 15;27(18):2026-9.
Bridwell and Ronald L DeWald. Lippincott-Raven Publishers, Philadelphia,
1997;pp1211-1254. 13. Marty C, Boisaubert B, Descamps H, Montigny JP, Hecquet J, Legaye J,Duval-
Beaupere G. The sagittal anatomy of the sacrum among young adults, infants,
4. Oxland TR: Biomechanics of the L5/S1 junction and the effect of and spondylolisthesis patients. Eur Spine J. 2002 Apr;11(2):119-25
Spondylolisthesis and Spondyloptosis. In Harms J, Sturz H eds: Severe
SYMPOSIA SPINE

Sponsylolisthesis. Steinkopff Verlag Darmstadt, 2002. pp. 53-66 14. Boulay C, Tardieu C, Hecquet J, Benaim C, Mouilleseaux B, Marty C, Prat-Pradal
D, Legaye J, Duval-Beaupere G, Pelissier J. Sagittal alignment of spine and pelvis
5. Abumi K, Panjabi M, Kramer KM, Duranceau J, Oxland T, Crisco JJ: regulated by pelvic incidence: standard values and prediction of lordosis.Eur
Biomechanical evaluation of lumbar spinal stability after graded facectomies. Spine J. 2006 Apr;15(4):415-22. Epub 2005 Sep 23.
Spine 1990;15(11):1142-1147.
15. Labelle H, Roussouly P, Berthonnaud E, Transfeldt E, O'Brien M, Chopin
6. Yue WM, Brodner W, Gaines RW. Abnormal spinal anatomy in 27 cases of surgi- D,Hresko T, Dimnet J. Spondylolisthesis, pelvic incidence, and spinopelvic bal-
cally corrected spondyloptosis: proximal sacral endplate damage as a possible ance: a correlation study. Spine. 2004 Sep 15;29(18):2049-54.
cause of spondyloptosis. Spine. 2005 Mar 15;30(6 Suppl):S22-6
16. Labelle H, Roussouly P, Berthonnaud E, Dimnet J, O'Brien M. The importance of
7. During J, Goudfrooij H, Keessen W, et al. Toward standards for posture: postural spino-pelvic balance in L5-s1 developmental spondylolisthesis: a review of perti-
characteristics of the lower back system in normal and pathologic conditions. nent radiologic measurements. Spine. 2005 Mar 15;30(6 Suppl):S27-34
Spine 1985;10:83–7.
17. Boxall D, Bradford DS, Winter RB, Moe JH. Management of severe spondylolis-
8. Duval-Beaupere G, Schmidt C, Cosson P. A barycentremetric study of the sagittal thesis in children and adolescents. J Bone Joint Surg Am. 1979 Jun;61(4):479-95.
shape of spine and pelvis: the conditions required for an economic standing
position. Ann Biomed Eng 1992;20:451–62. 18. Bradford DS, Boachie-Adjei O. Treatment of severe spondylolisthesis by anterior
and posterior reduction and stabilization. A long-term follow-up study. J Bone
9. Jackson RP, Peterson MD, McManus AC, et al. Compensatory spinopelvic bal- Joint Surg Am. 1990 Aug;72(7):1060-6.
ance over the hip axis and better reliability in measuring lordosis to the pelvic
radius on standing lateral radiographs of adults volunteers and patients. Spine 19. Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D.: The
1998;23:1750–67. natural history of spondylolysis and spondylolisthesis: 45-year follow-up evalua-
tion. Spine. 2003 May 15;28(10):1027-35; discussion 1035.
10. MacThiong JM, Labelle H, Berthonnaud E, et al. Sagittal alignment of the spine
and pelvis during growth. Spine 2004;29:1642–7.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
268 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 269

EVALUATION AND TREATMENT OF THE PEDIATRIC PATIENT

WITH ISTHMIC/LYTIC SPONDYLOLISTHESIS
John P. Dormans MD

Definition: Clinical Evaluation:

1. Spondylolisthesis - forward displacement of a vertebrae over 1. Majority of patients are asymptomatic

SYMPOSIA SPINE
the next adjacent segment 2. Back pain is the most common complaint in symptomatic
2. Spondylolysis – defect in the pars interarticularis without patients
any forward slippage of the vertebrae • may have radicular pain
• onset of pain is usually insidious
Classification:
3. Neurologic symptoms
1. Wiltse-Newman:
4. Hamstring tightness
• 5 types – dysplastic, Isthmic, degenerative, traumatic and
5. Gait abnormalities – hip flexed, knee flexed gait
pathologic
6. Flattening of lumbar lordosis
• only types I and II apply to children and adolescents
7. Scoliosis is seen in 40% of cases
Congenital/Dysplastic: • should be treated separately
1. Results from inherent spinal anomalies such as deficient or
Imaging Studies:
maloriented lumbar or lumbosacral facets.
1. Standing PA and lateral radiographs of the lumbosacral
2. Higher rates of progression compared to isthmic/lytic type.
spine
3. Less common than the isthmic type.
2. Oblique radiographs of the lumbosacral spine
Isthmic/Lytic Spondylolisthesis 3. SPECT scan
1. Developmental 4. MRI
2. Results from a defect/fracture in the pars interarticularis. 5. CT scan
3. Stress fracture due to excessive stress applied on the lumbar 6. Urodynamics
spine • may be indicated pre-operatively especially in patients
4. Hereditary factors with high grade spondylolisthesis
5. Trauma
Radiographic Evaluation:
Incidence: 1. Meyerding classification – degree of slip severity
1. 4-8% incidence • grade I - 0-25%
2. Male affected more than females (2:1) • grade II - 26-50%
3. High grade slips more common in females • grade III - 51-75%
• grade IV - 76 – 100%
Pathogenesis:
• grade V – spondyloptosis.
1. The lumbar spine is subject to high shear forces and com-
2. Slip angle
pressive load.
• Measures the degree of lumbosacral kyphosis
2. The bony hook, comprised of the pedicle, the pars interar-
• SA > 50° associated with progression
ticularis and the inferior facets resists shear forces, provides
3. Pelvic incidence (fig. 1)
stability and prevents slippage.
• estimates overall pelvic morphology
3. The loss of the posterior restraint allows forward displace-
• constant anatomic variable and helps determine sacral
ment of one vertebral segment over the next more caudal
slope, pelvic tilt and lumbar lordosis
level
• increased pelvic incidence and lumbar lordosis seen in
Natural History: patients with spondylolysis and low grade slips
1. McPhee et al, found increase rates of progression in dysplas- • PI in children 47°, adults 57°.
tic/congenital spondylolisthesis as compared to isthmic • Increased PI predispose to the development of spondy-
type. lolisthesis
2. Buetler et al, in a 45 year follow-up study reviewing 500
Management:
children screened from 1955, found no progression in
1. Non-operative management:
patients with unilateral pars defects. Progression slowed
• Asymptomatic spondylolysis or low grade spondylolis-
with each decade. Low grade slips followed a clinical course
thesis – observation
similar to the general population.
• Symptomatic spondylolysis or low grade spondylolisthe-
3. Harris and Weinstein found 36% of patients treated non-
sis –
operatively were asymptomatic, 55% had mild symptoms
— activity modification
and 45% had neurologic findings.
— physical therapy
Risk Factors for Progression: — brace treatment – anti-lordotic
1. Grade of the slip 2. Operative management
2. Gender F>M • Indicated for symptomatic spondylolytic defects or low
3. Slip angle of >50° grade slips with failed non operative management
4. Younger age at presentation • High grade slips (III or IV) with or without neurologic
5. Increased pelvic incidence (>47° in children) - controversial compromise
• Select appropriate management for each individual case
— a thorough evaluation of the patient
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
269
SYM 07:Layout 1 1/12/07 11:41 AM Page 270

— an in depth understanding of the natural history and 2. Sacroplasty

patholoanatomy 3. Posterior fusion stabilized by pedicle screw instrumenta-
— understanding the indications and goals of treatment tion.
— understanding the limitations of each procedure and 4. Thorough PLIF/discectomy and fibular strut grafting or cage
its possible complications to add anterior column support
• Decompression is always indicated in cases with neuro-
Post-operative Management:
logic involvement
1. Pain control
— decompression should always be accompanied by
2. Thoraco-lumbo-sacral orthosis for comfort
fusion
3. activity restriction/modification until fusion has been docu-
• Reduction
SYMPOSIA SPINE

mented
— controversial
— reduction with pedicle screw instrumentation – most Complications:
widely used technique 1. Pseudoarthrosis
¬ ADVANTAGES: • most common complication
– improved cosmesis • signs: lucency around implants, implant breakage, slip
– improved canal stenosis progression
– improved sagittal balance\ • minimized by using meticulous technique and proper
– restoration of normal to near normal lum- preparation of graft site
bosacral articulation 2. Neurologic compromise:
¬ DISADVANTAGES: • root lesions (L5 root)
– longer operative time • from direct trauma, manipulation of nerve roots, epidur-
– technically demanding al hematoma formation (compression)
– increased blood loss • cauda equine syndrome
– increased complication rate • autonomic dysfunction
• Instrumented fusion techniques: • chronic pain
— increased stability • immediate release of correction should be done when
— increased fusion rates necessary
— earlier immobilization • thorough evaluation with proper imaging techniques
• minimized by good pre-op planning and meticulous sur-
Goals in Treatment:
gical technique and by using multi-modality spinal cord
1. Ultimate goal in treating spondylolisthesis is to restore
monitoring
sagittal balance
3. Transition syndromes:
2. Reduction of slip angle more important than the percentage
• spondylolisthesis acquisita
of slip
• adjacent segment degeneration
3. Anterior column support for high grade
• S1-S2 deformity
4. Treat the patient not the radiographs
4. Loss of reduction due to inadequate fixation
5. Avoid complications – good monitoring
SURGICAL TREATMENT:
Isolated Repair of Pars Defect
1. Bucks fusion
2. Scott wiring technique
3. Pedicle screw repair
In Situ Posterolateral Arthrodesis:
1. bilateral lateral fusion 22
• from transverse process to sacral alae
2. indicated for symptomatic grade I or II spondylolisthesis
3. good fusion rates (83 – 95%)
Bohlmann Technique 2
1. indicated for symptomatic high grade slips
2. postural reduction with fibular auto or allograft JAAOS 2006; 14: 488-498
Fig. 1 the pelvic incidence is the angle formed between a line drawn
4-step CHOP Decompression and Instrumented Fusion perpendicular to the center of the sacral end plate (A) and a line drawn from the
1. Wide laminectomy and decompression of L5 nerve roots center of the femoral head to the center of the sacral end plate (B).

REFERENCES 4. DeWald, C. J.; Vartabedian, J. E.; Rodts, M. F.; and Hammerberg, K. W.:
1. Beutler, W. J.; Fredrickson, B. E.; Murtland, A.; Sweeney, C. A.; Grant, W. D.; and Evaluation and management of high-grade spondylolisthesis in adults. Spine,
Baker, D.: The natural history of spondylolysis and spondylolisthesis: 45-year fol- 30(6 Suppl): S49-59, 2005.
low-up evaluation. Spine, 28(10): 1027-35; discussion 1035, 2003. 5. Fujii, K.; Katoh, S.; Sairyo, K.; Ikata, T.; and Yasui, N.: Union of defects in the pars
2. Bohlman, H. H., and Cook, S. S.: One-stage decompression and posterolateral interarticularis of the lumbar spine in children and adolescents. The radiological
and interbody fusion for lumbosacral spondyloptosis through a posterior outcome after conservative treatment. J Bone Joint Surg Br, 86(2): 225-31, 2004.
approach. Report of two cases. J Bone Joint Surg Am, 64(3): 415-8, 1982. 6. Ganju, A.: Isthmic spondylolisthesis. Neurosurg Focus, 13(1): E1, 2002.
3. Cheung, E. V.; Herman, M. J.; Cavalier, R.; and Pizzutillo, P. D.: Spondylolysis 7. Gillet, P., and Petit, M.: Direct repair of spondylolysis without spondylolisthesis,
and spondylolisthesis in children and adolescents: II. Surgical management. J using a rod-screw construct and bone grafting of the pars defect. Spine, 24(12):
Am Acad Orthop Surg, 14(8): 488-98, 2006. 1252-6, 1999.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
270 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 271

8. Grzegorzewski, A., and Kumar, S. J.: In situ posterolateral spine arthrodesis for 16. Molinari, R. W.; Bridwell, K. H.; Lenke, L. G.; and Baldus, C.: Anterior column
grades III, IV, and V spondylolisthesis in children and adolescents. J Pediatr support in surgery for high-grade, isthmic spondylolisthesis. Clin Orthop Relat
Orthop, 20(4): 506-11, 2000. Res, (394): 109-20, 2002.
9. Hammerberg, K. W.: New concepts on the pathogenesis and classification of 17. Molinari, R. W.; Bridwell, K. H.; Lenke, L. G.; Ungacta, F. F.; and Riew, K. D.:
spondylolisthesis. Spine, 30(6 Suppl): S4-11, 2005. Complications in the surgical treatment of pediatric high-grade, isthmic dysplas-
10. Harris, I. E., and Weinstein, S. L.: Long-term follow-up of patients with grade-III tic spondylolisthesis. A comparison of three surgical approaches. Spine, 24(16):
and IV spondylolisthesis. Treatment with and without posterior fusion. J Bone 1701-11, 1999.
Joint Surg Am, 69(7): 960-9, 1987. 18. Nachemson, A. L.: Instability of the lumbar spine. Pathology, treatment, and
11. Hensinger, R. N.: Spondylolysis and spondylolisthesis in children. Instr Course clinical evaluation. Neurosurg Clin N Am, 2(4): 785-90, 1991.
Lect, 32: 132-51, 1983. 19. Nicol, R. O., and Scott, J. H.: Lytic spondylolysis. Repair by wiring. Spine, 11(10):

SYMPOSIA SPINE
12. Labelle, H.; Roussouly, P.; Berthonnaud, E.; Transfeldt, E.; O'Brien, M.; Chopin, 1027-30, 1986.
D.; Hresko, T.; and Dimnet, J.: Spondylolisthesis, pelvic incidence, and spin- 20. Roussouly, P.; Gollogly, S.; Berthonnaud, E.; Labelle, H.; and Weidenbaum, M.:
opelvic balance: a correlation study. Spine, 29(18): 2049-54, 2004. Sagittal alignment of the spine and pelvis in the presence of L5-s1 isthmic lysis
13. Lenke, L. G.; Bridwell, K. H.; Bullis, D.; Betz, R. R.; Baldus, C.; and Schoenecker, P. and low-grade spondylolisthesis. Spine, 31(21): 2484-90, 2006.
L.: Results of in situ fusion for isthmic spondylolisthesis. J Spinal Disord, 5(4): 21. Shufflebarger, H. L., and Geck, M. J.: High-grade isthmic dysplastic spondylolis-
433-42, 1992. thesis: monosegmental surgical treatment. Spine, 30(6 Suppl): S42-8, 2005.
14. Lonstein, J. E.: Spondylolisthesis in children. Cause, natural history, and manage- 22. Wiltse, L. L.: The paraspinal sacrospinalis-splitting approach to the lumbar spine.
ment. Spine, 24(24): 2640-8, 1999. Clin Orthop Relat Res, (91): 48-57, 1973.
15. McPhee, I. B.; O'Brien, J. P.; McCall, I. W.; and Park, W. M.: Progression of lum- 23. Wiltse, L. L.; Newman, P. H.; and Macnab, I.: Classification of spondylolisis and
bosacral spondylolisthesis. Australas Radiol, 25(1): 91-5, 1981. spondylolisthesis. Clin Orthop Relat Res, (117): 23-9, 1976.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
271
SYM 07:Layout 1 1/12/07 11:41 AM Page 272

SPONDYLOLYSIS AND THE ADOLESCENT ATHLETE

J. Abbott Byrd III, MD

Anatomy Non-operative Treatment

• Superior Articular Facet • Chronic Spondylolysis
• Pars Interarticularis — Rest
• Inferior Articular Facet — NSAID
— Brief Immobilization
SYMPOSIA SPINE

Classification
— Serial Radiographs Until Mature To R/O
• Dysplastic
Spondylolisthesis
• Isthmic
• Acute Spondylolysis
• Degenerative
— TLSO
• Traumatic
— Rest
• Pathological
— No NSAID
Wiltse, Newman, Mcnab Clin Orthop 1976;117:23-29.
— Serial Radiographs To Document Healing
Spondylolysis — If Fracture Heals And Symptoms Resolve Allow Return To
Isthmic Type Activity
• Lytic-Fatigue Fracture — If Fracture Doesn’t Heal And Symptoms Resolve Allow
• Elongation Return To Activity And
• Acute Fracture-Traumatic Event — Monitor For Recurrence Of Symptoms
— If Fracture Doesn’t Heal And Symptoms Persist Consider
Patient Symptoms
Surgical Treatment
• Low Back Pain
• Activity Related Operative Treatment
• Minimal LEP • L5-S1 Fusion
• Direct Repair
Patient Signs
— Buck Screw Technique JBJS Br 1970;52:432-437.
• Low Back Tenderness
— Scott Wire Technique JBJS Br 1992;74:426-430.
• Normal Reflexes
— Kakiuchi Pedicle Screw-Hook Technique JBJS Am
• Normal Motor
1997;79:818-825.
• Normal Sensory
• Possible Hamstring Tightness Activity Recommendations
No restrictions after fracture repair heals and symptoms resolve
Radiographic Evaluation
• Standing PA, Lateral and Obliques Summary
• Scotty Dog – Neck-Pars, Ear- SAF, Foot-IAF, Nose-Transverse • Pars Interarticularis Defect
Process • Mechanical LBP
• 20% Incidence of Unilateral Defect • Must R/O Other Etiologies
• Non-op Tx – Rest, Medication & Bracing
Radiographic Evaluation
• Surgery – Rarely Necessary But Direct Repair If Needed
• SPECT Bone Scan
• Unrestricted Activity Allowed After Symptoms Resolve
— Distinguish Acute vs. Chronic Defect
• CT Scan
— Distinguish Acute vs. Chronic Defect

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
272 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 273

EVALUATION AND TREATMENT OF THE ADULT PATIENT WITH

ISTHMIC, LYTIC SPONDYLOLISTHESIS
Mark Weidenbaum, MD

Background — Injections – pars, selective nerve root, epidural (discogra-

• General info phy7)

SYMPOSIA SPINE
— Definition – isthmic (pars defect) in > age18 — Bracing -limited value
— Developmental, not congenital — Address other pathology – hip/knee
— Prevalence 6% > 18 y/o (↑ Eskimo, ↓ African- • Surgical Indications
American); most asymptomatic30 — Progressive neuro deficit (rare)
— Etiology – unclear; genetic, bio-mechanical , anatomic, — Symptomatic Grade 3,4, or 5
traumatic factors2,31 — >6-12 months LBP or sciatica unresponsive to non-oper-
• Mechanism ative care Grade 0-2
— Repetitive lumbar extension ¬ Radiographic instability, slip progression
¬ Initial - cephalad inferior facet = “guillotine” effect on ¬ Confirm that pars/slip is really the problem
caudal pars — Prior surg/work
¬ Late – disc degeneration • Surgical Options
— Risk factors (5%) — Lysis repair5,16 – isolated LBP
¬ Usually L5-S1 — Fusion
¬ Hx trauma - ↑ gymnastics, linemen, wrestlers ¬ Literature unclear18 on which technique is best, but
¬ Hx kyphosis (Scheuermann’s) - compensatory lordo fusion does work9,14,24,34
¬ Lysis ♀<♂ (2:1), listhesis ♀>♂ (4:1) ¬ Decompress?
¬ Progression - occurs with disc degeneration (but ¬ Yes – excise hypertrophic fibrous tissue, open foramen
rare)9 — For radiculopathy, neural symptoms
¬ No - ↑ risk pseudo/progression; if get solid fusion →
Clinical Assessment don’t need to decompress1,6
• Presentation ¬ Instrument?
— Often have an “inciting event” (but many are asympto- ¬ Higher fusion/complication rates
matic)37 — Doesn’t help1,11,29
— Back > leg pain, but leg pain often is what drives visit to ¬ Un-instrumented –good for elderly, low demand,
doctor poor bone quality
— L5 symptoms, but actual neuro deficit rare ¬ Reduce?
¬ Lateral process → more proximal root (lateral) affect- ¬ In situ- +/- decompression or instrumentation
ed 17 ¬ Correct L-S kyphosis
¬ Since L5-S1 level most common, usually L5 root ¬ Lower pseudo/better cosmesis vs. higher complica-
— Lumbar hyperlordosis, trunk shortening (only if high tions32
grade) ¬ High grade
• Radiographs — Totally different issues3,10,35
— Lumbosacral – ¬ Add ant support?- Cage/graft
¬ Bony detail ¬ yes
¬ Obliques – “Scotty dog” — TLIF12,13,19,24,27,33
¬ Flex/ext – instability39 — PLIF4,21,28,38
¬ Ferguson view – titled view compensate for LS kyphosis — ALIF
¬ % slip, slip angle (segmental kyphosis), remodeling — Combined A/P20,36
— 36” standing long-cassette films – associated deformity, ¬ Smokers, revisions, reduction
global balance (particularly sagittal)34 ¬ No
• Imaging — PLF clinical outcome better than PLIF8,26
— SPECT – minimal value in adults ¬ MIS Approach18,25
— CT (thin slice) +/- myelo – best for bony pathology;
localize lesion; confirm diagnosis; plan surgery A New Perspective
— MRI – • Pelvic Incidence14,15,22,23,40 – ( Roussouly, Labelle)
¬ Shows neuro-compression best — Definition – PI; anatomical signature; not positional
¬ especially useful when neuro deficit is present or with — PI = SS (sacral slope) + PT (pelvic tilt); SS, PT are vari-
unusual presentation able positional parameters
¬ assess hydration status of adjacent levels — Provides quantifiable measures of sagittal spino-pelvic
balance
Management ¬ More global view of spondylo on entire spine(not just
• Non-operative management L-S region)
— PT (flexion)/exercise ¬ Shear vs. “nutcracker”34
— Meds – NSAIDs, muscle relaxants, narcotics, PO steroids
— Weight loss, stop smoking, job modification, etc

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
273
SYM 07:Layout 1 1/12/07 11:41 AM Page 274

REFERENCES 21. La Rosa, G.; Conti, A.; Cacciola, F.; Cardali, S.; La Torre, D.; Gambadauro, N. M.;
1. Adam, F. F.: Surgical management of isthmic spondylolisthesis with radicular and Tomasello, F.: Pedicle screw fixation for isthmic spondylolisthesis: does pos-
pain. Int Orthop, 27(5): 311-4, 2003. terior lumbar interbody fusion improve outcome over posterolateral fusion? J
Neurosurg, 99(2 Suppl): 143-50, 2003.
2. Boszczyk, B. M.; Boszczyk, A. A.; Boos, W.; Korge, A.; Mayer, H. M.; Putz, R.;
Benjamin, M.; and Milz, S.: An immunohistochemical study of the tissue bridg- 22. Labelle, H.; Roussouly, P.; Berthonnaud, E.; Dimnet, J.; and O'Brien, M.: The
ing adult spondylolytic defects--the presence and significance of fibrocartilagi- importance of spino-pelvic balance in L5-s1 developmental spondylolisthesis: a
nous entheses. Eur Spine J, 15(6): 965-71, 2006. review of pertinent radiologic measurements. Spine, 30(6 Suppl): S27-34, 2005.

3. Bradford, D. S., and Boachie-Adjei, O.: Treatment of severe spondylolisthesis by 23. Labelle, H.; Roussouly, P.; Berthonnaud, E.; Transfeldt, E.; O'Brien, M.; Chopin,
anterior and posterior reduction and stabilization. A long-term follow-up study. J D.; Hresko, T.; and Dimnet, J.: Spondylolisthesis, pelvic incidence, and spin-
Bone Joint Surg Am, 72(7): 1060-6, 1990. opelvic balance: a correlation study. Spine, 29(18): 2049-54, 2004.
SYMPOSIA SPINE

4. Brantigan, J. W., and Neidre, A.: Achievement of normal sagittal plane alignment 24. Lauber, S.; Schulte, T. L.; Liljenqvist, U.; Halm, H.; and Hackenberg, L.: Clinical
using a wedged carbon fiber reinforced polymer fusion cage in treatment of and radiologic 2-4-year results of transforaminal lumbar interbody fusion in
spondylolisthesis. Spine J, 3(3): 186-96, 2003. degenerative and isthmic spondylolisthesis grades 1 and 2. Spine, 31(15): 1693-
8, 2006.
5. Buck, J. E.: Direct repair of the defect in spondylolisthesis. Preliminary report. J
Bone Joint Surg Br, 52(3): 432-7, 1970. 25. Lee, S. H.; Choi, W. G.; Lim, S. R.; Kang, H. Y.; and Shin, S. W.: Minimally inva-
sive anterior lumbar interbody fusion followed by percutaneous pedicle screw
6. Carragee, E. J.: Single-level posterolateral arthrodesis, with or without posterior fixation for isthmic spondylolisthesis. Spine J, 4(6): 644-9, 2004.
decompression, for the treatment of isthmic spondylolisthesis in adults. A
prospective, randomized study. J Bone Joint Surg Am, 79(8): 1175-80, 1997. 26. Madan, S., and Boeree, N. R.: Outcome of posterior lumbar interbody fusion ver-
sus posterolateral fusion for spondylolytic spondylolisthesis. Spine, 27(14):
7. Cohen, M. W.; Maurer, P. M.; and Balderston, R. A.: Preoperative evaluation of 1536-42, 2002.
adult isthmic spondylolisthesis with diskography. Orthopedics, 27(6): 610-3,
2004. 27. McAfee, P. C.; DeVine, J. G.; Chaput, C. D.; Prybis, B. G.; Fedder, I. L.;
Cunningham, B. W.; Farrell, D. J.; Hess, S. J.; and Vigna, F. E.: The indications for
8. Dehoux, E.; Fourati, E.; Madi, K.; Reddy, B.; and Segal, P.: Posterolateral versus interbody fusion cages in the treatment of spondylolisthesis: analysis of 120
interbody fusion in isthmic spondylolisthesis: functional results in 52 cases with cases. Spine, 30(6 Suppl): S60-5, 2005.
a minimum follow-up of 6 years. Acta Orthop Belg, 70(6): 578-82, 2004.
28. Molinari, R. W.; Sloboda, J. F.; and Arrington, E. C.: Low-grade isthmic spondy-
9. Floman, Y.: Progression of lumbosacral ishtmic spondylolisthesis in adults. lolisthesis treated with instrumented posterior lumbar interbody fusion in U.S.
Spine, 25: 342, 2000. servicemen. J Spinal Disord Tech, 18 Suppl: S24-9, 2005.
10. Gaines, R. W., and Nichols, W. K.: Treatment of spondyloptosis by two stage L5 29. Moller, H., and Hedlund, R.: Instrumented and noninstrumented posterolateral
vertebrectomy and reduction of L4 onto S1. Spine, 10(7): 680-6, 1985. fusion in adult spondylolisthesis--a prospective randomized study: part 2. Spine,
11. Gehrchen, P. M.; Dahl, B.; Katonis, P.; Blyme, P.; Tondevold, E.; and Kiaer, T.: No 25(13): 1716-21, 2000.
difference in clinical outcome after posterolateral lumbar fusion between patients 30. O'Brien, M. F.: Low-grade isthmic/lytic spondylolisthesis in adults. Instr Course
with isthmic spondylolisthesis and those with degenerative disc disease using Lect, 52: 511-24, 2003.
pedicle screw instrumentation: a comparative study of 112 patients with 4 years
of follow-up. Eur Spine J, 11(5): 423-7, 2002. 31. Patwardhan, A.; Ghanayem, A.; Simonds, J.; Hodges, S.; Voronov, L.; Paxinos, O.;
and Havey, R.: An experimental model of adult-onset slip progression in isthmic
12. Hackenberg, L.; Halm, H.; Bullmann, V.; Vieth, V.; Schneider, M.; and Liljenqvist, spondylolistesis. Stud Health Technol Inform, 91: 322-4, 2002.
U.: Transforaminal lumbar interbody fusion: a safe technique with satisfactory
three to five year results. Eur Spine J, 14(6): 551-8, 2005. 32. Petraco, D. M.; Spivak, J. M.; Cappadona, J. G.; Kummer, F. J.; and Neuwirth, M.
G.: An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction.
13. Houten, J. K.; Post, N. H.; Dryer, J. W.; and Errico, T. J.: Clinical and radiographi- Spine, 21(10): 1133-8; discussion 1139, 1996.
cally/neuroimaging documented outcome in transforaminal lumbar interbody
fusion. Neurosurg Focus, 20(3): E8, 2006. 33. Potter, B. K.; Freedman, B. A.; Verwiebe, E. G.; Hall, J. M.; Polly, D. W., Jr.; and
Kuklo, T. R.: Transforaminal lumbar interbody fusion: clinical and radiographic
14. Huang, R. P.; Bohlman, H. H.; Thompson, G. H.; and Poe-Kochert, C.: Predictive results and complications in 100 consecutive patients. J Spinal Disord Tech,
value of pelvic incidence in progression of spondylolisthesis. Spine, 28(20): 18(4): 337-46, 2005.
2381-5; discussion 2385, 2003.
34. Roussouly, P.; Gollogly, S.; Berthonnaud, E.; Labelle, H.; and Weidenbaum, M.:
15. Jackson, R. P.; Phipps, T.; Hales, C.; and Surber, J.: Pelvic lordosis and alignment Sagittal alignment of the spine and pelvis in the presence of L5-s1 isthmic lysis
in spondylolisthesis. Spine, 28(2): 151-60, 2003. and low-grade spondylolisthesis. Spine, 31(21): 2484-90, 2006.
16. Kakiuchi, M.: Repair of the defect in spondylolysis. Durable fixation with pedicle 35. Sailhan, F.; Gollogly, S.; and Roussouly, P.: The radiographic results and neuro-
screws and laminar hooks. J Bone Joint Surg Am, 79(6): 818-25, 1997. logic complications of instrumented reduction and fusion of high-grade spondy-
17. Kim, K. W.; Chung, J. W.; Park, J. B.; Song, S. W.; Ha, K. Y.; and An, H. S.: The lolisthesis without decompression of the neural elements: a retrospective review
course of the nerve root in the neural foramen and its relationship with forami- of 44 patients. Spine, 31(2): 161-9; discussion 170, 2006.
nal entrapment or impingement in adult patients with lumbar isthmic spondy- 36. Spruit, M.; Pavlov, P. W.; Leitao, J.; De Kleuver, M.; Anderson, P. G.; and Den
lolisthesis and radicular pain. J Spinal Disord Tech, 17(3): 220-5, 2004. Boer, F.: Posterior reduction and anterior lumbar interbody fusion in sympto-
18. Knight, M., and Goswami, A.: Management of isthmic spondylolisthesis with matic low-grade adult isthmic spondylolisthesis: short-term radiological and
posterolateral endoscopic foraminal decompression. Spine, 28(6): 573-81, 2003. functional outcome. Eur Spine J, 11(5): 428-33, 2002.
19. Kwon, B. K.; Berta, S.; Daffner, S. D.; Vaccaro, A. R.; Hilibrand, A. S.; Grauer, J. N.; 37. Stone, A. T., and Tribus, C. B.: Acute progression of spondylolysis to isthmic
Beiner, J.; and Albert, T. J.: Radiographic analysis of transforaminal lumbar inter- spondylolisthesis in an adult. Spine, 27(16): E370-2, 2002.
body fusion for the treatment of adult isthmic spondylolisthesis. J Spinal Disord 38. Suk, S. I.; Lee, C. K.; Kim, W. J.; Lee, J. H.; Cho, K. J.; and Kim, H. G.: Adding pos-
Tech, 16(5): 469-76, 2003. terior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion
20. Kwon, B. K.; Hilibrand, A. S.; Malloy, K.; Savas, P. E.; Silva, M. T.; Albert, T. J.; and after decompression in spondylolytic spondylolisthesis. Spine, 22(2): 210-9; dis-
Vaccaro, A. R.: A critical analysis of the literature regarding surgical approach and cussion 219-20, 1997.
outcome for adult low-grade isthmic spondylolisthesis. J Spinal Disord Tech, 18 39. Vaccaro, A. R.; Martyak, G. G.; and Madigan, L.: Adult isthmic spondylolisthesis.
Suppl: S30-40, 2005. Orthopedics, 24(12): 1172-7; quiz 1178-9, 2001.
40. Vaz, G.; Roussouly, P.; Berthonnaud, E.; and Dimnet, J.: Sagittal morphology and
equilibrium of pelvis and spine. Eur Spine J, 11(1): 80-7, 2002.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
274 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 275

DEGENERATIVE AND POSTSURGICAL SPONDYLOLISTHESIS

John Dimar, MD

I. Definition: A Spondylolisthesis is Defined as the Forward VII. Spinal Claudication & Radiculopathy - Pathogenesis of
Translation of one Vertebrae on Another in the Sagittal Nerve Compression Two-fold
Plane of the Spine. 1. Displacement of One Vertebra Upon Another Causing
Central Stenosis
II. Classification
2. Degenerative Facet Hypertrophy Causing

SYMPOSIA SPINE
6 Types:
Lateral/Foraminal Stenosis
1. Dysplastic/Congenital
2. Isthmic VIII. Surgical Treatment
3. Degenerative 1. Decompression alone
4. Traumatic 2. Decompression with concurrent fusion
5. Pathologic 3. Low Grade Spondylolithesis Fuse In Situ
6. Iatrogenic 4. Consider Reduction for High Grade Spondylolithesis
a. PLSF
III. Grading
b. TLIF
Meyerding Classification
c. AIBF
IV.Degenerative Spondylolithesis d. Combined AIBF/PSF
Epidemiolgy
*With or Without Concurrent Instrumentation and
1. More Elderly Population
Reduction – Current opinion concerning the treatment of
2. L4/5 Most Common Level- alar Ligaments Stabilization
degenerative spondylolisthesis, particularly if there is demon-
Effect
stratable excessive motion, is that an arthrodesis should be
3. Female Predominance
combined with the decompressive laminectomy.
4. Commonly Present with Radiculopathy
5. Distinct Predilection- Sagittally Oriented Facets IX. Surgical Techniques
1. PLSF –
*A Continuum of Progressive Spinal Degeneration-with
a. Adequate Central and Lateral Recess Decompression
aging of the spine the disc degenerates moving the axis of rota-
b. Meticulous Decortication of the Posterior Elements
tion posteriorly resulting in ligamentum flavum, interspinous
c. Beware of Dural Hypoplasia- Prevent a Dural Tear
ligament, and facet hypertrophy leading to eventual instability
d. Higher Grade Slips Have Distorted Anatomy
of the functional spinal unit and forward anterolithesis.
e. Inferior Pedicles May Have Significant pedicular cen-
V. Post-surgical Spondylolithesis tral sclerosis
1. An Inevitable Result of Decompression. f. Graft Material Should Always be Osteoinductive
2. Results in Rotational and/or Sagittal Instability 2. TLIF-
3. 50% rule of Facet Resection-varies from Level to Level a. Less Muscle Dissection
4. Frequently Develop Late Instability Requiring b. Potential for Disc Space Elevation and Reduction
Stabilization c. Modest Improvement in Lordosis
d. Provides for a 360 Degree Fusion Without an Anterior
VI. Diagnostic Modalities
Approach
1. Plain Radiographs
e. Adaptable to a Minimally Invasive Approach
2. “Dynamic” Lateral Flexion/extension Radiographs
f. Dramatic Improvement in Instrumentation and
3. MRI
Implants Facilitating Surgery
4. Myelogram/CT scan
g. The potential that rhBMP Has Changed the Biologics
VI. Conservative Treatment of Fusion for the Procedure Resulting in Improved
1. Activity Modification Fusion Success
2. NDAID’s 3. ALIF –
3. Bracing a. Excellent Restoration of Lordosis
4. Weight reduction b. High Fusion Rate – rhBMP-2>ICBG
5. Limited Physical Therapy c. Lower Operative Time and Blood Loss
6. Epidural Blocks d. Maintenance of Lordosis – Protection Against
Adjacent Level Degenerative Disc Disease
*Limited Long Term Benefits – Most patients have an approx-
e. Shorter Hospital Stay
imate
f. Good Applicability to L4/5 and L5/S1 Levels
Window of Two Years before the need for surgical intervention
X. Conclusion
VII. Surgical Indications 1. Degenerative spondylolithesis is a commonly encoun-
1. Severe Radiculopathy tered spinal condition affecting the elderly population
2. Severe Low Back Pain and presents generally with the onset of spinal claudica-
3. Neurogenic Claudication tion, radiculopathy, or rarely back pain. There are now
4. Significant Disruption of Normal Daily Activities available numerous surgical techniques that are applicable
5. Instability to these patients that can dramatically improve their
6. Combination lifestyle. Careful patient selection, through preoperative

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
275
SYM 07:Layout 1 1/12/07 11:41 AM Page 276

medical clearance, thoughtful surgical judgment, and

proper training in the various techniques discussed will
insure excellent patient outcomes.
SYMPOSIA SPINE

REFERENCES 9. Grobler LJ, Wiltse LL: Classification, non-operative, and oper-ative treatment of
1. Amundson G, Edwards CC, Garfin SR: Spondylolisthesis. P.913. In Rothman RH, spondylolisthesis, in Frymoyer JW (ed): The Adult Spine: Principles and Practice.
Simeone FA (eds): Spine. 3rd Ed. Vol. 11, WB Saunders, Philadelphia, 1992. New York, RavenPress, Vol 2, pp 1655–1704, 1991.

2. Burkus JK, Gornet MF, Dickman CA, et al. Anterior Lumbar Interbody Fusion 10. Herkowitz HN, Kurz LT: Degenerative Lumbar Spondylolisthesis with Spinal
using rhBMP-2 With Tapered Interbody Cages. J Spinal Disord Tech 2002;15: Stenosis. A Prospective Study Comparing Decompression with Decompression
337-49. and Intertransverse Process Arthrodesis. J Bone Joint Surg Am 73(6):802-8, 1991.

3. Burkus JK, Transfeldt EE, Kitchel SH, et al. Clinical and Radiographic 11. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL,
Outcomes of Anterior Lumbar Interbody Fusion Using Recombinant Human Ditkoff JS: Degenerative Lumbar Spondylolisthesis with Spinal Stenosis: a
Bone Morphogenetic Protein-2. Spine 2002;27:2396-2408. Prospective Long-term Study Comparing Fusion and Pseudoarthrosis. Spine Apr
16;29(7):726-33; discussion 733-4, 2004.
4. Burkus JK, Sandhu HS, Gornet MF, et al. Use of rhBMP-2 in Combination
With Structural Cortical Allografts: Clinical and Radiographic Outcomes in 12. Meyerding HW: Spondylolisthesis. Surg Gynecol Obstet 54:371–377, 1932.
Anterior Lumbar Spinal Surgery. J Bone Joint Surg 2005;87-A:1205-12. 13. Nork SE, Hu SS, Workman KL, Glazer PA, Bradford DS: Patient outcomes after
5. Dimar JR, Djurasovic M, Carreon LY. Surgical Management of Degenerative decompression and instrumented posterior spinal fusion for degenerative
And Postsurgical Spondylolisthesis. Semin Spine Surg 2005;17:186-94. spondylolisthesis. Spine. Mar 15;24(6):561-9, 1999.

6. Dimar JR, Glassman SD, Burkus KJ, et al. Clinical Outcomes and Fusion Success 14. Panjabi MM: The stabilizing system of the spine. Part I. Function, dysfunction,
at 2 Years of Single-Level Instrumented Posterolateral Fusions With Recombinant adaptation, and enhancement. J Spinal Disord. Dec;5(4):383-9; discussion 397,
Human Bone Morphogenic Protein-2/Compression Resistant Matrix Versus Iliac 1992.
Crest Bone Graft. Spine 2006;31:2534-39. 15. Panjabi MM: The stabilizing system of the spine. Part II. Neutral zone and insta-
7. Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT: bility hypothesis. J Spinal Disord. Dec;5(4):390-6; discussion 397, 1992.
1997 Volvo Award Winner in Clinical Studies. Degenerative Lumbar 16. Potter, BK et al., Journal of Spinal Disorders & Techniques, Vol., No. 4, pp. 337-
Spondylolisthesis with Spinal Stenosis: a Prospective, Randomized Study 346, August 2005
Comparing Decompressive Laminectomy and Arthrodesis with and without 17. Schwender, JD et al., Journal of Spinal Disorders & Techniques, VOl. 18, No. 1S,
Spinal Instrumentation. Spine 22(24):2807-12, 1997. pp. 1-6, Feb. 2005
8. Fredrickson, Bruce E, MD: The Natural History of Spondylolysis and 18. Vukkavucebcuim AT. et al., Journal of Neurosurgery: Spine Vol. 3:436-443 Dec
Spondylolisthesis. The Journal of Bone and Joint Surgery, Jan (250)171-75, 1984. 2005

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
276 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 277

TOTAL DISC ARTHROPLASTY:

THE ART AND SCIENCE AS OF 2007

SYMPOSIA SPINE
(AAOS/ORSII)
Co- Moderators: Scott D. Boden, MD, Atlanta, GA (a, e - Medtronic, b, c - Osteotech) and
Dawn M. Elliot, PhD, Philadelphia, PA (a - Synthes Spine, a - Orthovita)

Disc arthroplasty remains a novel and controversial treatment with many questions
associated with optimal biomechanical design, biomechanical and biological effect on
adjacent disc levels, patient selection and exclusion criteria, and evaluation of patient
satisfaction. The first goal of this symposium is to review clinically relevant anatomy,
biomechanics, and biology in healthy and degenerated intervertebral disc tissue. In
addition, balanced summaries of the current state of cervical and lumbar spine total disc
arthroplasty will be presented, including clinical results. Future concerns and directions for
research will be discussed.

I. Disc Anatomy and Biomechanics

Ian A.F. Stokes, PhD, Burlington, VT (n)

II. Disc Biology

James D. Kang, MD, Pittsburgh, PA (a - Medtronic Sofamor Danek)

III. Cervical Spine Total Disc Arthroplasty

John G. Heller, MD, Atlanta, GA (c, d, e - Medtronic)

IV. Lumbar Spine Total Disc Arthroplasty

Jeffrey C. Wang, MD, Santa Monica, CA (b, e - Medtronics, e - DePuy, Synthes, Stryker,
Biomet)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
277
SYM 07:Layout 1 1/12/07 11:41 AM Page 278

DISC ANATOMY AND BIOMECHANICS - PHYSIOLOGICAL

REQUIREMENTS
Ian Stokes, PhD

Arthroplasty - surgery to retain joint function (including • Be stable i.e. not buckle (requires motion segment stiffness,
motion preservation) muscle preactivation, muscle response to perturbation)
SYMPOSIA SPINE

Biomechanics - mechanical behavior of the living system • Provide ranges of motion (6 -dof)
• Control the center or axis of rotation (CoR)
The problem:
— CoR not fixed (depends on loading)
1. Arthrodesis in the spine has a high rate of non-union.
— CoR not necessarily the center or axis of load transmis-
2. Arthrodesis may accelerate degeneration of 'adjacent seg-
sion, as it is in diarthroidial joints
ments'
— Determines strains etc. experienced by surrounding tis-
3. However, arthroplasty is challenging, revision is not desir-
sues and structures
able.
Interpreting clinical functional studies
The Disc is a central part of the Motion Segment
• Few in vivo biomechanical evaluations are available
• 0
• Radiographically measured motion
Components of the motion segment — Ranges of motions
• Disc — 'Pattern' of motion (multisegmental distribution by level,
— Annulus and Nucleus segmental center of rotation)
— Both consist of water, matrix proteins and cells. Tissues — In radiography it is difficult to control patient position,
have nonlinear elastic properties, time dependent prop- spinal loading
erties, high water content and low permeability, fixed
Interpreting mechanical tests
charge producing swelling pressure.
• Flexibility:- Load-displacement (apply compression load,
— The annulus has a highly organized architecture that (1)
shear force, 3 torques = 6 DOF)
contains pressure (2) allows motion with minimal tissue
• Stiffness:- Displacement-Load (apply 3 translations, 3 rota-
strain (except in torsion).
tions = 6 DOF)
• Facet (Zygoaphyseal) joints. 'Guide' motion.
• What's the 'neutral zone'? What's the 'elastic zone'?
• Ligaments. Limit motion
• Coupling (interactions of 'out-of-plane' displacements or
• Muscle attachments
forces)
— Most of the muscles are multi-articular
• Strength (Failure loads, number of cycles, modes of failure)
— There's a redundant number of muscles - providing
• Stability (in vivo - muscle responses in perturbation experi-
"choices" about activation strategies
ments)
• Nerve supply. For proprioception etc.
Different anatomical regions - different biomechanics - similar
• Blood supply. Transport of nutrients, metabolites and sig-
principles
naling molecules
• Cervical - large range of motion; lesser loading
• Vertebral endplate - has structural role and is a major path-
• Thoracic
way for transport
• Lumbar - lesser range of motion; high loading
Functional requirements of the Motion Segment
What's not known
• Be strong
• Biomechanics of disc homeostasis and degeneration
— not fail under physiological loading
• Biomechanics of pain
— not be damaged while under repetitively undergoing
• How to standardize evaluation of devices pre-clinically
range of motion
— mechanical testing protocols
• Have flexibility (not too much, not too little)
— suitable animal models

REFERENCES 7. Benneker LM, Heini PF, Alini M, Anderson SE, Ito K. 2004 Young Investigator
1. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease Award Winner: vertebral endplate marrow contact channel occlusions and inter-
after lumbar or lumbosacral fusion: review of the literature. Spine. 2004; vertebral disc degeneration. Spine. 2005; 30(2):167-73.
29(17):1938-44. 8. Urban JP, Smith S, Fairbank JC. Nutrition of the intervertebral disc. Spine. 2004 ;
2. Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degen- 29(23):2700-9.
eration in the lumbar spine. J Bone Joint Surg Am. 2004; 86-A(7):1497-503. 9. Rajasekaran S, Babu JN, Arun R, Armstrong BR, Shetty AP, Murugan S. ISSLS
3. Bergmark A: Stability of the lumbar spine. A study in mechanical engineering. prize winner: A study of diffusion in human lumbar discs: a serial magnetic reso-
Acta Orthop Scand, 1986; Suppl 230: 1-54 nance imaging study documenting the influence of the endplate on diffusion in
normal and degenerate discs. Spine. 2004; 29(23):2654-67.
4. Radebold A, Cholewicki J, Panjabi MM, Patel TC (2000) Muscle response pattern
to sudden trunk loading in healthy individuals and in patients with chronic low 10. Panjabi MM, Brand RA, White AA: Mechanical properties of the human thoracic
back pain. Spine 25(8):947-954 spine J. Bone Joint Surg Am, 1976; 58(5): 642-652.

5. Hutton WC, Malko JA, Fajman WA. Lumbar disc volume measured by MRI: 11. Gardner Morse MG, and Stokes IAF: Structural behavior of human lumbar
effects of bed rest, horizontal exercise, and vertical loading. Aviat Space Environ spinal motion segments. J Biomechanics, 2004, 37(2): 205-121.
Med. 2003; 74(1):73-8. 12. Leivseth G, Braaten S, Frobin W, Brinckmann P. Mobility of lumbar segments
6. Horner HA, Urban JP. 2001 Volvo Award Winner in Basic Science Studies: Effect instrumented with a ProDisc II prosthesis: a two-year follow-up study. Spine.
of nutrient supply on the viability of cells from the nucleus pulposus of the 2006; 31(15):1726-33.
intervertebral disc. Spine. 2001; 26(23):2543-9.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
278 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 279

13. Sariali el-H, Lemaire JP, Pascal-Mousselard H, Carrier H, Skalli W. In vivo study 15. Serhan HA, Dooris AP, Parsons ML, Ares PJ, Gabriel SM. In vitro wear assess-
of the kinematics in axial rotation of the lumbar spine after total intervertebral ment of the Charite Artificial Disc according to ASTM recommendations. Spine.
disc replacement: long-term results: a 10-14 years follow up evaluation. Eur Spine 2006; 31(17):1900-10.
J. 2006; 15(10):1501-10. 16. Rousseau MA, Bradford DS, Bertagnoli R, Hu SS, Lotz JC. Disc arthroplasty
14. Putzier M, Funk JF, Schneider SV, Gross C, Tohtz SW, Khodadadyan-Klostermann design influences intervertebral kinematics and facet forces. Spine J. 2006;
C, Perka - C, Kandziora F. Charite total disc replacement--clinical and radi- 6(3):258-66.
ographical results after an average follow-up of 17 years. Eur Spine J. 2006; 17. Goel VK, Grauer JN, Patel TCh, Biyani A, Sairyo K, Vishnubhotla S, Matyas A,
15(2):183-95. Cowgill I, Shaw M, Long R, Dick D, Panjabi MM, Serhan H. Effects of Charité
artificial disc on the implanted and adjacent spinal segments mechanics using a
hybrid testing protocol. Spine. 2005 Dec 15;30(24):2755-64.

SYMPOSIA SPINE

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
279
SYM 07:Layout 1 1/12/07 11:41 AM Page 280

BIOLOGY OF DISC DEGENERATION: AGING VERSUS

PAINFUL DEGENERATION
James D. Kang MD

I. Normal Disc Biology 1. Collagen I, III, VI, X

a. Nucleus Pulposus 2. Elastin, Fibronectin, Anyloid
SYMPOSIA SPINE

i. Chondrocytes maintain matrix homeostasis iii.GAGs reduced in production (net loss due to more
ii. Notochordal cells early in life, but disappear with breakdown and less synthesis)
aging
IV.Pain Generators from the Disc
b. Annulus Fibrosus
a. Herniated disc show increase innervation (normally
i. Chondrocytes in a collagenous network
aneural)
ii. Layers / Sheets of cells and matrix contains the NP
b. Nerve endings found in deeper layers of AF and occa-
c. Cartilage Endplate
sionally into the depth of the NP
i. Diffusion of nutrients into disc
c. Could be due to annular tears and ingowth of neuron-
ii. Export of waste products
vascular channels that grow into the clefts (discogenic
iii.Source of cells?
LBP?)
d. Matrix Components
d. Cytokines detected in the disc modulates pain
i. Type 2 Collagen in NP
i. Substance P
ii. Type 1 in AF
ii. Calcitonin Gene related peptide
iii.Aggrecan, Decorin, Biglycan
iii.Vasoactive intestinal polypeptide
iv. Other Collagens (III, VI, X and more)
iv. A degenerating disc eluting these cytokines can elicit
II. Aging Changes to the Disc sciatica leg pain
a. Regression of blood supply to the disc early in life (2 e. Discography
years of age0 i. Stimulates mechanical nocicpetors in the AF
b. Vascular endplates channels diminish (6-30months) ii. Concordant pain and clinical correlation very contro-
c. Increased numbers of clefts and tears versial
d. Presence of granular materials f. Other structures causing possible pain
e. Neovascularization from outer annulus i. Facet Joint arthritis
f. Cell proliferation, cluster formation ii. Ligaments and Muscular Pain
g. Greater cell death or apoptosis iii.Bone, vertebral body
h. Loss of clear demarcation from NP and AF during 2nd
V. Pain Perception and Modulation
decade
a. Subjective experience
i. Cracks and thinning of endplates, microfractures of
b. Activation by peripheral nociceptors
bone, sclerosis
c. Modulated by higher centers from brain
III. Pathologic Degeneration to the Disc i. Important issues in chronic LBP
a. Cellular Level ii. Psycosocial input
i. Disc cell proliferation and cell cluster formation
VI. Animal Models of Disc Degeneration
ii. Increase cell death (apoptosis and necrosis)
a. Rabbit puncture model of degeneration
b. Molecular Changes
b. Sandrat
i. Increase cytokines
c. Larger Models
1. MMPs, Interleukins, PGEs
d. No good animal models for a painful disc degeration
ii. Structural Matrix Proteins

REFERENCES: 8. Roberts S, Eisenstein SM, Menage J, Evans EH, Ashton IK. Mechanoreceptors in
1. Rufai A, Benjamin M, Ralphs JR. The development of fibrocartilage in the rat intervertebral discs. Morphology, distribution and neuropeptides. Spine.1995;
intervertebrl disc. Anat Embryol (Berl). 1995;192:53 -62. 20:2645 -51.

2. Pazzaglia UE, Salisbury JR, Byers PD. Development and involution of the noto- 9. Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, Nerlich AG. Classification
chord in the human spine. J R Soc Med. 1989;82:413 -5. of age-related changes in lumbar intervertebral discs. Spine.2002; 27:2631 -44.

3. Roberts S, Menage J, Urban JP. Biochemical and structural properties of the carti- 10. Edelson JG, Nathan H. Stages in the natural history of the vertebral end-plates.
lage end-plate and its relation to the intervertebral disc. Spine.1989; 14:166 -74. Spine.1988; 13:21 -6.

4. Chelberg MK, Banks GM, Geiger DF, Oegema TR Jr. Identification of heteroge- 11. Beadle OA. The intervertebral discs: observations on their normal and morbid
neous cell populations in normal human intervertebral disc. J Anat.1995; 186:43 anatomy in relation to certain spinal deformities. London: His Majesty's
-53. Stationery Office;1931 .

5. Errington RJ, Puustjarvi K, White IR, Roberts S, Urban JP. Characterisation of 12. Donohue PJ, Jahnke MR, Blaha JD, Caterson B. Characterization of link
cytoplasm-filled processes in cells of the intervertebral disc. J Anat.1998; 192:369 protein(s) from human intervertebral-disc tissues. Biochem J.1988; 251:739 -47.
-78 Johnson WE, Eisenstein SM, Roberts S. Cell cluster formation in degenerate lum-
bar intervertebral discs is associated with increased disc cell proliferation.
6. Marchand F, Ahmed AM. Investigation of the laminate structure of lumbar disc Connect Tissue Res.2001; 42:197 -207.
anulus fibrosus. Spine.1990; 15:402 -10.
13. Gruber HE, Hanley EN Jr. Analysis of aging and degeneration of the human
7. Yu J, Fairbank JC, Roberts S, Urban JP. The elastic fibre network of the anulus intervertebral disc. Comparison of surgical specimens with normal controls.
fibrosus of the normal and scoliotic human intervertebral disc. Spine.2005; Spine.1998; 23:751 -7
30:1815 -20.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
280 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 281

14. Trout JJ, Buckwalter JA, Moore KC. Ultrastructure of the human intervertebral 23. Roberts S, Evans H, Menage J, Urban JP, Bayliss MT, Eisenstein SM, Rugg MS,
disc: II. Cells of the nucleus pulposus. Anat Rec.1982; 204:307 -14. Milner CM, Griffin S, Day AJ. TNF alpha-stimulated gene product (TSG-6) and
15. Roberts S, Caterson B, Menage J, Evans EH, Jaffray DC, Eisenstein SM. Matrix its binding protein, IalphaI, in the human intervertebral disc: new molecules for
metalloproteinases and aggrecanase: their role in disorders of the human inter- the disc. Eur Spine J. 2005;14:36 -42.
vertebral disc.Spine . 2000;25:3005 -13. 24. Roberts S, Urban JP, Evans H, Eisenstein SM. Transport properties of the human
16. Roberts S, Menage J, Duance V, Wotton S, Ayad S. Collagen types around the cartilage endplate in relation to its composition and calcification. Spine.1996;
cells of the intervertebral disc and cartilage end plate: an immunolocalization 21:415 -20.
study. Spine.1991; 16:1030 -8. 25. Bibby SR, Fairbank JC, Urban MR, Urban JP. Cell viability in scoliotic discs in
17. Roberts S, Bains MA, Kwan A, Menage J, Eisenstein SM. Type X collagen in the relation to disc deformity and nutrient levels. Spine.2002; 27:2220 -8.
human intervertebral disc: an indication of repair or remodelling? Histochem 26. Johnson WE, Roberts S. Human intervertebral disc cell morphology and

SYMPOSIA SPINE
J.1998; 30:89 -95. cytoskeletal composition: a preliminary study of regional variations in health
18. Oegema TR Jr, Johnson SL, Aguiar DJ, Ogilvie JW. Fibronectin and its fragments and disease. J Anat. 2003;203:605 -12.
increase with degeneration in the human intervertebral disc. Spine.2000; 27. Leleo J. Basic science of pain. JBJS. 2006;88A-Supp 2,58-62.
25:2742 -7. 28. Brisby H. Pathology and possible mechanisms of Nervous system response to
19. Kauppila LI. Ingrowth of blood vessels in disc degeneration. Angiographic and disc degeneration. JBJS. 2006:881-Supp 2, 68-71.
histological studies of cadaveric spines. J Bone Joint Surg Am.1995; 77:26 -31. 29. Sobajima S, Kompel JF, Kim JS, Wallach CJ, Robertson DD, Vogt MT, Kang JD,
20. Freemont AJ, Watkins A, Le Maitre C, Baird P, Jeziorska M, Knight MT, Ross ER, Gilbertson LG: “A Slowly Progressive and Reproducible Animal Model of Disc
O'Brien JP, Hoyland JA. Nerve growth factor expression and innervation of the Degeneration Characterized by MRI, Xray,and Histology.” Spine, 30(1):15-24,
painful intervertebral disc. J Pathol. 2002;197:286 -92. 2005.
21. Hilton RC, Ball J, Benn RT. Vertebral end-plate lesions (Schmorl's nodes) in the 30. Sobajima S, Shimer AL, Chadderdon RC, Kompel JF, Kim JS, Gilbertson LG,
dorsolumbar spine. Ann Rheum Dis. 1976;35:127 -32. Kang JD: “Quantitative Analysis of Gene Expression in a Rabbit Model of
22. Twomey L, Taylor J. Age changes in lumbar intervertebral discs. Acta Orthop Intervertebral Disc Degeneration by real time RT-PCR.” The Spine Journal, 5:14-
Scand.1985; 56:496 -9. 23, 2005.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
281
SYM 07:Layout 1 1/12/07 11:41 AM Page 282

CERVICAL DISC REPLACEMENT:

FROM PRE-CLINICAL TESTING TO HUMAN TRIALS
John G. Heller, MD

*Disclosure: The presenter serves as a consultant to Medtronic, technology that would be applied after a standard ACDF, which
Inc. regarding this subject matter. He is also a stockholder in and when inserted could preserve to normal load bearing and kine-
SYMPOSIA SPINE

receives royalties from Medtronic, Inc. matics of the subaxial cervical motion segment (C3-7). This
device was also meant to be inherently stable at the time of
Spine surgeons have long considered the indications for and
insertion and throughout its functional life span, biocompati-
results of anterior cervical discectomy and fusion to well estab-
ble, similar in cushioning effect to the native disc, compatible
lished and reliable. The inherent trade-off between segmental
with available imaging technologies, and amenable to revision,
motion and symptom relief appeared quite favorable. In
if necessary. A device was designed comprised of a pair of tita-
exchange for relief from their complaints and functional
nium shells, which present a porous coated bone in-growth sur-
deficits, patients tolerated activity restrictions, brace wear, bone
face to the host bone, and a central polyurethane core. After
graft donor sites, and the potential for re-operation due to
extensive in vitro testing in static and fatigue modes, as well as
symptomatic non-unions. The equation also seemed to
physiologic motion simulators up to 40 million cycles, in vivo
improve with time and innovations in internal fixation meth-
animal testing was undertaken.
ods, bone graft procurement and even the recent ‘off label’ use
of BMP-2. A survivor study was initially performed in ten adult male chim-
panzees, to most closely simulate the human condition. The
The 20th century saw a revolution in care for arthritic weight
devices were retrieved after 3 or 6 months, and anterior cervical
bearing joints as innovative technologies shifted surgical care
fusions performed at the time of explantation. With encourag-
from fusion to motion sparing arthroplasties. Though coined
ing results, investigators moved forward with toxicity studies in
originally in reference to posterior lumbar fusion, the notion of
a caprine model. The goats were sacrificed after variable periods
‘fusion disease’ encouraged investigators to forge further ahead
of in vivo wear, so that local and systemic toxicity issues could
with concepts in disc replacement. Initially the focus was on
be investigated via autopsy. Particulate wear debris was identi-
lumbar disc replacements. The first cervical disc replacements
fied, but did not ellicit a cellular inflammatory reaction.
were performed in the early 1990s and reported by Cummins,
Whereas the control group with plated ACDFs showed typical
et al. in 1998. Though successful at maintaining some motion
cellular reactions to titanium particulates shed at the screw-plate
in ‘salvage’ situations adjacent to prior fusions, the device was
junction. No systemic or local neurotoxic effects were evident.
hardly engineered to its purpose. Applied engineering has
helped evolve the original Cummins’ device into its contempo- Prospective, non-randomized human clinical trials with the
rary form, the Prestige? artificial disc, that has completed a Bryan device began in Europe in January, 2000. Trials with other
prospective multi-center randomized clinical trial (IDE), ulti- devices would follow thereafter, including the evolution of the
mately leading to a recommendation for ‘approval’ following a Cummins’ device. As reported by Goffin et al., the Bryan clini-
United States FDA panel hearing. cal results have proven encouraging and durable out to maxi-
mum of six-year follow-up. Most recently, Goffin reported four
The indications for implantation of an artificial cervical disc fol-
to six year clinical results at the 2006 Cervical Spine Research
lowing spinal cord or nerve root decompression are fairly
Society meeting. Eighty eight per cent (61/69) of single level
restrictive. In contrast to lumbar disc replacement procedures,
cases were rated as ‘excellent’ (41) or ‘good’ (20) in his single
the diagnoses and indications for surgical intervention in these
center follow-up report. The spontaneous fusion rate was noted
patients are clear and accepted internationally. Candidates for
to be 17 per cent, which was slightly greater than the overall rate
these procedures are patients with persistent cervical radicu-
of spontaneous fusion reported at two years with the European
lopathy or myelopaty due to cervical disc herniations. Their his-
multi-center trial. The presence or absence of spontaneous
tory, physical examination and imaging studies should be con-
fusion did not affect the clinical result.
sistent with the diagnosis. The affected disc space must be suffi-
ciently mobile on flexion-extension radiographs. Segmental Favorable clinical results have by no means been unique to one
instability, facet arthropathy and significant spondylosis should technology. Currently in press, the results from the United States
also be excluded by appropriate diagnostic studies. Thus these IDE study of the Prestige? ST stainless steel cervical disc replace-
patients are a small subset of those who might otherwise be ment, which evolved from the Cummins’ device, are most
appropriate candidates for an anterior cervical decompression encouraging. The prospective, multi-center, randomized clinical
and fusion. Morris et al. recently reported on the proportion of trial enrolled 541 patients undergoing single-level discecomties
patients who might meet the criteria for disc replacement for cervical radiculopathy or myelpathy due to a disc herniation.
among 100 consecutive ACDF patients. They applied the same The investigational group consisted of 276 subjects, while 265
inclusion/exclusion criteria as those employed in the FDA clin- randomized to the control procedure, a conventional ACDF
ical trials. Only 9 percent of patients met the criteria. However, with an interbody allograft and plate. Improvements in the
if the possibility of multi-level surgeries existed (all U.S. IDE tri- Neck Disability Index and SF-36 scores were noteworthy and
als have been restricted to single-level surgery), as many as 30 equivalent among the two groups. The device maintained a
percent of patients might be eligible to forgo fusions and mean of 7 degrees of motion at the implanted level. At mini-
employ prosthetic cervical discs. mum two-year follow-up the investigational cohort showed sta-
tistically better performance with respect neurologic success
By way of example, the Bryan? cervical disc replacement is
(p=0.005), revision surgeries (p=0.003). The arthroplasty group
offered as an example a device engineered to its intended pur-
returned to work earlier than control (p=0.001). The ‘Overall
pose. Its inventor, neurosurgeon Vincent Bryan, conceived of a
Success’ criteria defined by the FDA, a composite measure of
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
282 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 283

safety and efficacy, was 77.6% and 66.4% in the investigational fuse disc spaces in the face of myelopathy is probably perception
and control groups, respectively (p=0.005). These results for the rather than reality.
Prestige? ST were consistent with previous less rigorous study
Anderson et al. employed pooled data analysis from a number
results from European investigators (Wigfield: Spine, 2002,
of similarly indicated one-level anterior cervical surgeries to
J.Neurosurg.Spine 2002).
investigate the re-operation rates for ACDFs versus arthroplas-
Delamarter, et al. recently presented preliminary results from ties. They complied the result from 649 arthroplasties and 580
the United States IDE for the ProDisc-C? at the 2006 Cervical ACDFs. There were 1.8% versus 3.6% re-operations in the disc
Spine Research Society meeting. Though the comparative results replacement and ACDF groups, respectively (p=0.055). Re-oper-
from the ACDF control group could not yet be released by the ations at the adjacent levels were more frequent among fusion

SYMPOSIA SPINE
sponsor, the authors indicated meaningful reductions in neck patients (p=0.01), while they were comparable at the operated
and arm pain VAS scores, which were durable over the follow- level.
up interval. Oswestry scores were similarly improved over time.
Data from at least three other cervical disc replacement IDE
The mean range of motion was said to be 6 degrees.
studies are not yet available. These include the Cervicore?, PCM?
Spontaneous fusion was noted in less than ten percent of cases,
and Kineflex-C?. But a pattern of fairly consistent results appears
but was thought to be site specific. The latter data are consistent
to be emerging. In contrast to lumbar disc replacement proce-
with the report from Mehren et al. (Spine 2006) in which the
dures, the diagnoses and indications for surgical intervention
authors report on their results in 54 patients. Approximately 9
are clear and accepted internationally. Meaningful and, in at
percent of the implanted segments had spontaneously fused,
least some cases, statistically superior clinical results are noted at
whereas nearly two-thirds had some evidence of radiographic
two-year follow-up among one or more of the multi-center
bone formation at the implanted level.
United States clinical trials. The observations are consistent with
The United States IDE study has also been concluded for the the less rigorous study results from outside the United States. As
Bryan? device. But as of the time of this writing, the data are not more studies are reported and follow-up intervals increase the
yet in the public domain. However, a three center pooled data durability of these initial findings will become clear. More
subset analysis was reported by Sasso, et al. at the 2006 Cervical importantly, we will learn the answers to fundamental ques-
Spine Research Society meeting. They reported on 115 of the tions, such as the affect of these technologies on the rates of
patients from the 463 entered into the clinical trial. Statistically adjacent segment degeneration.
superior performance out to two year follow-up was reported
In closing, one would be remiss not to offer a word of caution.
for the investigational subjects with regard to Neck Disability
Like any new technology, there are bound to be lessons learned.
Index scores (0.005), arm pain VAS scores (p=0.014), neck pain
It seems unlikely that each of the many devices in use through-
VAS scores (p=0.005), SF-36 Physical Component scores
out the world will prove equally effective, many of which have
(p=0.009), and twice the number of re-operations among the
not been subjected to rigorous pre-clinical testing. The learned
controls.
spine surgeon should keep an open but appropriately skeptical
Other reports at recent meetings have looked at other points of mind on the data as they are revealed. Over time we will refine
interest regarding the clinical efficacy of cervical disc replace- the indications and contraindications for these procedures.
ments. Riew et al. reported on the use of an artifical disc versus Long term clinical follow-up will reveal designs and materials
an ACDF in the treatment of myelopathic patients with single- which are oppropriate, and others that will require modifica-
level disc herniations. Their study pooled the results from the tion. Open and objective reporting of both successes and fail-
Bryan? and Prestige? IDE studies for this subset of enrolled ures will allow these procedures to find their proper place
patients. In comparing the result of 107 arthroplasty patients to among the surgical options available to patients with cervical
99 control subjects, they found no significant difference in the radiculopathy and myelopathy.
various outcome measures. The authors noted that the need to

REFERENCE 8. DiAngelo DJ, Foley KT, Morrow BR et al. In vitro biomechanics of cervical disc
1. Allen MJ, Myer BJ, Millett PJ et al. The effects of particulate cobalt, chromium arthroplasty with the ProDisc-C total disc implant. Neurosurg.Focus. 2004;17:E7.
and cobalt-chromium alloy on human osteoblast-like cells in vitro. J.Bone Joint 9. DiAngelo DJ, Roberston JT, Metcalf NH et al. Biomechanical testing of an artifi-
Surg.Br. 1997;79:475-82. cial cervical joint and an anterior cervical plate. Journal of Spinal Disorders &
2. Anderson PA, Rouleau JP, Bryan VE et al. Wear analysis of the Bryan Cervical Disc Techniques.16(4):314-23, 2003.
prosthesis. Spine 2003;28:S186-S194. 10. Eck JC, Humphreys SC, Lim TH et al. Biomechanical study on the effect of cervi-
3. Anderson PA, Sasso RC, Metcalf NH et al. Reoperation Rates for Cervical cal spine fusion on adjacent-level intradiscal pressure and segmental motion.
Arthroplasty vs Arthrodesis. (Abstract) Spine Line: 22, (July/August) 2006. Spine.27(22):2431-4, 2002.

4. Anderson PA, Sasso RC, Rouleau JP et al. The Bryan Cervical Disc: wear proper- 11. Fuller DA, Kirkpatrick JS, Emery SE et al. A kinematic study of the cervical spine
ties and early clinical results. Spine Journal: Official Journal of the North before and after segmental arthrodesis. Spine.23(15):1649-56, 1998.
American Spine Society.4(6 Suppl):303S-309S, 2004;-Dec. 12. Gelb H, Schumacher HR, Cuckler J et al. In vivo inflammatory response to poly-
5. Bohlman HH, Emery SE, Goodfellow DB et al. Robinson anterior cervical discec- methylmethacrylate particulate debris: effect of size, morphology, and surface
tomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one area.[erratum appears in J Orthop Res 1994 Jul;12(4):598]. Journal of
hundred and twenty-two patients. Journal of Bone & Joint Surgery - American Orthopaedic Research.12(1):83-92, 1994.
Volume.75(9):1298-307, 1993. 13. Goffin J, Casey A, Kehr P et al. Preliminary clinical experience with the Bryan
6. Cummins BH, Robertson JT, Gill SS. Surgical experience with an implanted artifi- Cervical Disc Prosthesis.[see comment]. Neurosurgery.51(3):840-5; discussion
cial cervical joint. J.Neurosurg. 1998;88:943-8. 845-7, 2002.

7. Delamarter RB, Pradhan BB, Kropf MA, Kanim LEA, Bae HW: Cervical disc 14. Goffin J, Geusens E, Vantomme N et al. Long-term follow-up after interbody
replacement: Over 3-year prospective randomized clinical outcomes and range of fusion of the cervical spine. Journal of Spinal Disorders & Techniques.17(2):79-
motion follow-up with the ProDisc-C Prosthesis. (Abstract) Presented at the 34th 85, 2004.
Annual Meeting of the Cervical Spine Research Society: Palm Beach, FL. 15. Goffin J, Van CF, van LJ et al. Intermediate follow-up after treatment of degenera-
December, 2006. tive disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level.
Spine.28(24):2673-8, 2003.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
283
SYM 07:Layout 1 1/12/07 11:41 AM Page 284

16. Goffin J, van LJ, Van CF et al. Long-term results after anterior cervical fusion 27. Puschak TJ, Sasso RC. The Use of Artificial Disc Replacement in Degenerative
and osteosynthetic stabilization for fractures and/or dislocations of the cervical spine. Conditions of the Cervical Spine. 2005.
Journal of Spinal Disorders.8(6):500-8; discussion 499, 1995. Ref Type: Unpublished Work
17. Goffin J, van Loon J, van Calenberg F: Cervical arthroplasty with the Bryan Disc: 28. Riew KD, Sekhon L, Metcalf N, Sasso RC, Anderson PA, Liu G: Cervical disc
4- and 6-year results. (Abstract) Presented at the 34th Annual Meeting of the arthroplasty versus arthrodesis for myelopathy: a prospective, randomized, con-
Cervical Spine Research Society. December, 2006, Palm Beach, FL. trolled trial. (Abstract) Presented at the 34th Annual Meeting of the Cervical
18. Gonzalez O, Smith RL, Goodman SB. Effect of size, concentration, surface area, Spine Research Society: Palm Beach, FL. December, 2006.
and volume of polymethylmethacrylate particles on human macrophages in 29. Sasso RC, Heller JG, Hacker R. Artificial disc versus fusion: a prospective, ran-
vitro. Journal of Biomedical Materials Research.30(4):463-73, 1996. domized study with 2-year follow-up on 99 patients. (Abstract) Presented at the
19. Goodman SB, Fornasier VL, Kei J. The effects of bulk versus particulate ultra- 34th Annual Meeting of the Cervical Spine Research Society: Palm Beach, FL.
SYMPOSIA SPINE

high-molecular-weight polyethylene on bone. Journal of Arthroplasty.3 December, 2006.

Suppl:S41-6, 1988. 30. Sasso RC, Rouleau JP. Cervical Kinematics in ACDF and Disc - Replaced Subjects.
20. Goodman SB, Huie P, Song Y et al. Cellular profile and cytokine production at 2004. NASS 20th Annual Meeting - Submitted Abstract.
prosthetic interfaces. Study of tissues retrieved from revised hip and knee replace- Ref Type: Unpublished Work
ments. Journal of Bone & Joint Surgery - British Volume.80(3):531-9, 1998.
31. Sekhon LH. Cervical arthroplasty in the management of spondylotic myelopathy.
21. Goodman SB, Lind M, Song Y et al. In vitro, in vivo, and tissue retrieval studies Journal of Spinal Disorders & Techniques.16(4):307-13, 2003.
on particulate debris. [Review] [76 refs]. Clinical Orthopaedics & Related
Research.(352):25-34, 1998. 32. Silber JS, Anderson DG, Daffner SD et al. Donor site morbidity after anterior iliac
crest bone harvest for single-level anterior cervical discectomy and fusion.
22. Heller JG, Smucker JD. In Situ Bryan Cervical Disc Post Procedure Images. 2005. Spine.28(2):134-9, 2003.
Ref Type: Unpublished Work 33. St John TA, Vaccaro AR, Sah AP et al. Physical and monetary costs associated with
23. Hilibrand AS, Carlson GD, Palumbo MA et al. Radiculopathy and myelopathy at autogenous bone graft harvesting. American Journal of Orthopedics (Chatham,
segments adjacent to the site of a previous anterior cervical arthrodesis. Journal Nj).32(1):18-23, 2003.
of Bone & Joint Surgery - American Volume.81(4):519-28, 1999. 34. Wigfield C, Gill S, Nelson R et al. Influence of an artificial cervical joint com-
24. Mehren C, Suchomel P, Grochulla F, Barsa P, Sourkova P, Hradil J, Korge A, pared with fusion on adjacent-level motion in the treatment of degenerative cer-
Mayer HM: Heterotopic ossification in total cervical artificial disc replacement. vical disc disease. J.Neurosurg.Spine 2002;96:17-21.
Spine. 31 (24): 2802-2806, 2006. 35. Wigfield CC, Gill SS, Nelson RJ et al. The new Frenchay artificial cervical joint:
25. Medtronic Sofamor Danek. Bryan Cervical Disc System - Single Level Surgical results from a two-year pilot study. Spine.27(22):2446-52, 2002.
Technique. 2004. Medtronic Sofamor Danek USA, Inc.
Ref Type: Pamphlet
26. Morris SF, Pappou I, Girardi FP, Cammisa FP: Prevalence of cervical spondylosis
amenable to disc arthroplasty. (Abstract) Presented at the 34th Annual Meeting
of the Cervical Spine Research Society: Palm Beach, FL. December, 2006.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
284 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 285

LUMBAR SPINE TOTAL DISC ARTHROPLASTY.

Jeffrey C. Wang, MD

Lumbar disc arthroplasty — 60 pts

• Degenerative disc disease can be treated with total disc — Results are comparable between two groups
arthroplasty • Zigler et al. J Spinal Disord Tech 2003
• The results of disc arthroplasty are not known for long-term — Difference is ODQ at 3 months
studies — No difference in VAS

SYMPOSIA SPINE
• The initial studies are case series and not well-controlled — Trend towards greater pt satisfaction at 6 months favor-
• The FDA studies are class I prospective studies and are actu- ing disc arthroplasty (p=0.08)
ally quite well performed, but company sponsored.
Lumbar Disc Arthroplasty
• The issue of conflict of interest is always an issue in regards
• Overall good results
to the investigators of these studies
• Comparable to fusion studies in the literature
Lumbar fusion • Comparable to fusion group in comparative studies
• Lumbar fusion is quite well-studied and there are multiple • Trends towards better outcomes in early results
studies looking at the results of fusion • But, may be equivalent by 6 months
• The comparison of disc arthroplasty may be possible to • Need longer follow-up
determine the benefits of each technology • Differences may disappear at 6 months
• Trends compared to fusion
Indications for disc arthroplasty
— Less operative time
• The FDA studies are well-controlled and the indications are
— Less blood loss
for single-level usage at L4-5 or L5-S1
— Less hospital stay
• There cannot be instability or other diagnoses that may
— No graft site problems
interfere with spinal stability or lead to neurological com-
— No pseudarthrosis issues
pression
— Single-level do better than multi-level
• There is not a direct correlation between patients who are
— Patients with no prior surgery do better than patients
candidates for disc arthroplasty and fusion as the patients
with prior surgery
who have instability, trauma, tumors, multi-level disease,
and scoliosis are all possible candidates for fusion Preservation of Motion
• Disc arthroplasty would be excluded from these diagnoses • Normal lumbar segments average approximately 14 degrees
• Some series average half that amount after disc implanta-
Disc arthroplasty devices
tion
• Total disc replacement typically involves two articulating
— Cinotti et al. Spine 1996 – 9 degrees
surfaces
— Bertagnoli et al. Eur Spine J 2002 – 7 degrees
• The bearing surfaces are the primary difference in design
— Kostuik. Spine 1996
• Polyethelene surfaces, metal on metal, and those that incor-
— Delamarter et al. Spine 2004
porate other metals are some of the articulating surfaces
¬ Fusion to disc replacement
• The ability of restriction of motion in certain planes and the
¬ L4-5 greater motion in disc group compared to fusion
amount of subluxation are also different among different
(p<0.05)
devices
¬ L5-S1 motion was not significantly different from
• Each is typically implanted from an anterior approach
fusion group
• Surgeons may extend the indications to multi-level proce-
— Cunningham et al. Eur Spine J 2002
dures
¬ Non-human primate model
Fusion vs Arthroplasty ¬ 12 month f/u
• Lumbar disc arthroplasty ¬ Disc group did not have significantly more motion
— 66% to 90% satisfactory results than fusion group
• ALIF • Are we restoring normal motion?
— 65% to 93% satisfactory results — Probably not
• Circumferential fusion — Is the motion compromised before surgery?
— 80% to 90% good to excellent results — Expect more than exisiting motion?
• PLIF • Needs more studies
— 80% to 90% good to excellent results
Adjacent Segment Disease
Direct Comparative Studies • The development of ASD is controversial
• Geisler et al Spine 2004 — Does it differ from the natural history of degeneration?
— 304 pts — Does disc arthroplasty decrease the incidence?
— Complications overall equivalent • Does disc arthroplasty decrease adjacent segment disease?
— Equivalent or better outcomes compared to control — Has not been demonstrated
group and historical controls in literature — Some motion preservation devices show increased adja-
• Delamarter et al. Spine 2004 cent segment degeneration
— 53 pts — Need long-term follow-up
— Pain and disability/outcomes equivalent to fusion group
Complication rates
• McAfee et al. Spine 2003
• Zeegers et al. Eur Spine J 1999
• McAfee et al. J Spinal Disord Tech 2003
— 13% permanent side-effect/complications
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
285
SYM 07:Layout 1 1/12/07 11:41 AM Page 286

— 6/50 reoperation rate = 12% — Facet joint arthrosis 11/27 = 41%

• Mayer et al. Eur Spine J 2002 — Migration 5/27 = 19%
— 8.8%
Lumbar Disc Arthroplasty
• Cinotti et al. Spine 1996
• Early results promising
— 8/46 reoperation rate = 17%
• Not better than fusion
• Van Ooij et al. J Spinal Disord Tech 2003
• Not sure how much motion we preserve
— 27 pts with complications
• Not sure if we change adjacent segment disease
— Mean presentation 53 months (11-127) after implanta-
• Long-term complications
tion
• Need long-term studies
— 26 pts with overall no benefit (12 temporary)
SYMPOSIA SPINE

• Answers are not negative, just not proven

— ASD 14/27 = 52%
— Subsidence 16/27 = 60%

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
286 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 287

DEGENERATIVE DISC (H)

Moderator: David W. Polly, Jr., MD, Minneapolis, MN (e - Medtronic)

SYMPOSIA SPINE
Discuss artificial disks, minimally invasive techniques, payor perspective related to levels of
evidnece for treatment and surgery. Patient outcome metrics SF 36 and Oswestry Disability
index as common tools for comparison of interventions.

I. Artificial Disks
Rick Guyer, MD, Plano, TX (a, c, e - DePuy Spine, a - Synthes, Abbott Spine, Medtronic)

II. Minimally Invasive Techniques

James Schwender, MD, Minneapolis, MN (c, e - Medtronic Sofamor Danek)

III. Levels of Evidence for covering Treatment and Surgery from a Payor’s Perspective
Thomas Marr, MD, Bloomington, MN (n)

IV. Patient Outcome Metrics SF 36 and Oswestry Disability

David W. Polly, Jr., MD, Minneapolis, MN (e - Medtronics)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
287
SYM 07:Layout 1 1/12/07 11:41 AM Page 288

MOTION PRESERVATION TECHNOLOGIES AND THEIR OUTCOME

Richard D. Guyer, MD

Introduction Maverick
The goal of motion preservation technology is to significantly Preliminary 24-month data was recently presented for 50
reduce pain while allowing motion of the spine. The tradition- patients who received the Maverick disc replacement. Patients
al treatment for many painful spinal problems was fusion. improved significantly based on pain and Oswstry scores.
While the results of this procedure were acceptable, it left the
SYMPOSIA SPINE

operated segment(s) rigid. Although controversial, there is sup- Other TDRs

port that fusion results in accelerated degeneration of the adja- Early results from other TDRs are becoming available and show
cent segments, making them vulnerable to becoming sympto- the same trends as for the implants completing their IDE trials.
matic. In this presentation, the clinical outcome of various
motion preserving technologies will be discussed. NUCLEUS REPLACEMENTS
Hydrogels
Total Disc Replacement (TDR)
The first modern attempt at nucleus replacement was the PDN
The motion preservation technology that has been in wide-
(prosthetic disc nucleus). Initially there were some problems
spread use the longest is TDR. It was first used in the mid 1980s
with displacements of the implant, but redesign has seemed to
in Germany with the introduction of the first version of the
significantly reduce this occurrence. Early results for this
CHARITÉ. The third design of that disc was introduced in 1987
implant have been favorable.3 A large scale trial will soon be ini-
and the basic design has remained the same, although now
tiated in the US.
available in a greater range of sizes, a porous coating on the end-
plates and more user-friendly insertion instrumentation have
Injectables
been incorporated.
Several designs of nucleus replacements incorporate the injec-
tion of elastic materials into the nuclear cavity. To date, there is
CHARITÉ
little data available on such devices.
The first disc studied under FDA-regulated protocol in the US
was the CHARITÉ Artificial Disc. The results of the FDA clinical
Mechanical replacements
trial found that the TDR and fusion groups improved signifi-
The other classes of nuclear replacements are those that are
cantly compared to their pre-operative status.1 At most follow-
mechanical such as the NuBacTM. To date, no clinical data has
up periods, the CHARITÉ group had more favorable scores on
been published for these implants.
VAS and Oswestry questionnaires than did the fusion group.
Satisfaction, assessed at the 12 and 24-month follow-up visits,
POSTERIOR DYNAMIC STABILIZATION
was greater among the CHARITÉ patients than among fusion
patients. The TDR group also had a significantly lower re-oper- Pedicle screw based dynamic systems
ation rate. Five-year data is currently being collected. There are several posterior dynamic systems. One of the first
Radiographic assessment found that the flexion/extension range such systems was the Graf. In a study with mean 7 year follow-
of motion (ROM) increased 13% in the CHARITÉ group (at 24- up after Graf ligamentoplasty.2 Excellent or good results were
month) and this group also had greater restoration and main- noted in 62% of patients with 61% reporting significant or total
tenance of disc space height compared to fusion.5 back-pain relief.
As with any new treatment, concern has been expressed over the The Dynesys device has been in use for several years as well.
long-term viability of TDRs. Lemaire et al. from Europe have Results of a multi-center study in Europe found that the mean
reported 10 to 13 year follow-up of 100 patients who received pain and function scores improved significantly post-operative-
the CHARITÉ.4 Good to excellent clinical results were reported ly.6 Re-operation was undertaken in 18% of patients.
for 90% of patients with more than 90% of patients working.
The prostheses were still mobile with the mean range of motion Total facet arthroplasty
at the implanted levels was 10.3o. Secondary arthrodesis was There are several total facet joint replacements undergoing clin-
required in 5% of the patients during the 10-year follow-up. ical evaluation. These are pedicle screw based implants.

ProDisc Interspinous spacers

The FDA clinical trial results have recently been presented but To date, four interspinous spacer systems have been described.
are not yet published. In that trial, the PRoDisc was compared The X STOP is the only one that has undergone a FDA IDE trial
to instrumented combined anterior-posterior fusion. ProDisc and was designed for the treatment of spinal stenosis. The
patients had a significantly greater proportion of patients who results of that study found that at 24-month follow-up, the X
reached the threshold for being defined as a successful outcome. STOP patients had greater improvements in symptoms and
The mean ROM of the operated levels was 7.7o. Re-operation function that did the non-operative control groups. Satisfaction
was required in 4% of patients during the 24-month follow-up. was also greater.8 Other interspinous devices are currently being
evaluated in clinical trials.
ProDisc was first implanted in France in 1990 and 7 to 11 year
follow-up of 55 patients was recently published.7 Excellent to
Summary
good results were noted in 75% of patients. Fusion was subse-
The results of various motion preserving technologies have been
quently performed in 5.4% of patients.
promising and data from Europe supports that the results are
sustained long-term. As with any surgery, careful patient selec-
tion is required to achieve these favorable outcomes.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
288 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 289

REFERENCES 5. McAfee PC, Cunningham B, Holsapple G, et al. A prospective, randomized, mul-

1. Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicen- ticenter Food and Drug Administration investigational device exemption study of
ter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar
lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: Part II: Evaluation of radiographic outcomes and correlation of surgical
fusion: part I: evaluation of clinical outcomes. Spine 2005;30:1565-75. technique accuracy with clinical outcomes. Spine 2005;30:1576-83.

2. Gardner A, Pande KC. Graf ligamentoplasty: A 7-year follow-up. Eur Spine J 6. Stoll TM, Dubois G, Schwarzenbach O. The dynamic neutralization system for
2002;11(Suppl 2):S157-63. the spine: a multi-center study of a novel non-fusion system. Eur Spine J 2002;11
Suppl 2:S170-8.
3. Jin D, Qu D, Zhao L, et al. Prosthetic disc nucleus (PDN) replacement for lum-
bar disc herniation: preliminary report with six months' follow-up. J Spinal 7. Tropiano P, Huang RC, Girardi FP, et al. Lumbar total disc replacement. Seven to
Disord Tech 2003;16:331-7. eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-6.

SYMPOSIA SPINE
4. Lemaire JP, Carrier H, Sariali el H, et al. Clinical and radiological outcomes with 8. Zucherman JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized
the Charite artificial disc: A 10-year minimum follow-up. J Spinal Disord Tech trial evaluating the X STOP interspinous process decompression system for the
2005;18:353-9. treatment of neurogenic intermittent claudication: two-year follow-up results.
Spine 2005;30:1351-8.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
289
SYM 07:Layout 1 1/12/07 11:41 AM Page 290

SURGICAL TREATMENT OF SYMPTOMATIC LUMBAR DISC

DEGENERATION: ARTHRODESIS
James Schwender, MD

Outline: Posterior interbody (PLIF, TLIF)

Types of Surgery: • Exposure:
SYMPOSIA SPINE

1. Anterior — Posteriorly based

2. Anterior and Posterior (A/P) — Open vs. Minimally Invasive Surgery (MIS)
3. Posterior — Unilateral vs. bilateral facetectomy
— Posterior-lateral (PL) • Muscle retraction:
— Posterior interbody — Kawaguchi Spine 1994, 1996
¬ Posterior lumbar interbody fusion (PLIF) — Retractor duration and pressure caused an increase in
¬ Transforminal lumbar interbody fusion (TLIF) creatine phosphokinase MM isoenzyme
4. Lateral approaches ¬ Suwa Neurol Med Chir 2000
XLIF – MRI evaluation of paraspinal mm. thickness
i. Ozgur Spine 2006 Jul-Aug; 6(4):435-43. Extreme – Most decrease seen in PL fusion
Lateral Interbody Fusion (XLIF): a novel surgical – Highest CKP in PL fusion group
technique for anterior lumbar interbody fusion. ¬ Kim et al Spine 2006
– MIS vs. Open PLIF
Anterior
– Significant reduction in CPK, aldolase and
• Exposure:
cytokines in MIS group
— Retroperitoneal vs. Transperitoneal
• MIS Exposure:
— No limit on number of fused levels
— Watkins and Wiltse JBJS 1953, 1968
— Lordosis restoration
¬ Muscle splitting approach
• Limitations:
– Sacrospinalis mm. medial
— Need for assisting surgeon
– Longissimus and iliocostalis mm. laterally
— Visceral and vascular injury
¬ Direct access to the majority of lumbar pathology
— Ventral hernia
¬ In-line access to the pedicles and the disc space
— Revisions are difficult 2nd scarring around the vessels
¬ Access to the transverse processes
• Interbody constructs:
— Paramedian incision 4-5 cm off midline
— Structural autograft
• Limitations:
— Structural allograft
— General:
— Metal (cages, mesh, etc.)
¬ Technically demanding
— Plastics
¬ Potentially lower fusion rates
— Biologics (PLLA, PLA, etc.)
– Kwon Spine 2005; 5(6 Suppl):224S-230S. Carrier materials for spinal
¬ Nerve root injury
fusions ¬ Failure to achieve correction of sagittal plane deformity
– Burkus Spine 2006 Apr 1;31(7):775-81 Influence of rhBMP-2 on the heal- — PLIF
ing patterns associated with allograft interbody constructs in comparison ¬ High rate of incidental durotomy
with autograft. ¬ Nerve root injury ( transversing) 2nd to medial retrac-
• Instrumentation: tion
— Anterior plating: — TLIF
¬ Midline applied at L5-S1 below the bifurcation of iliac ¬ Unilateral anulotomy with potentially less disc
vessels removal
¬ Lateral at higher lumbar segments • Interbody constructs:
¬ L4-5 contraindicated based on vascular anatomy — Structural autograft
— Posterior: — Metal (cages, mesh, etc.)
¬ Pedicle screw based systems — Plastics
¬ Facet screw based systems — Biologics (PLLA, PLA, etc.)
• Outcomes: • Outcomes:
— Fusion rates: — Fusion rates & Clinic Outcomes
90-100% reported ¬ Schwender et al J Spinal Disord Tech. 2005 Feb;18
— Clinic Outcomes Suppl:S1-6. Minimally invasive transforaminal lum-
¬ Fritzell Spine 2002 Jun 1;27(11):1131-41. Chronic bar interbody fusion (TLIF): technical feasibility and
low back pain and fusion: a comparison of three sur- initial results.
gical techniques: a prospective multicenter random- – VAS 7.2-2.1
ized study from the Swedish lumbar spine study – ODI 46-14
group. ¬ Kim et al Spine 2006 May 20;31 (12):1351-7. Clinical
– AP fusion rate 91% outcomes of 3 fusion methods through the posterior
– PL fusion rate 87% approach in the lumbar spine.
¬ 85% improvement average with PLF, PLIF, and
PLIF/PLF

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
290 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 291

WHAT DO HEALTH PLANS REQUIRE FOR SPINE SURGERY?

Thomas J. Marr, MD

Financial Relationships — Persistent, unresponsive, debilitating low back pain for at

• None least six months
— Refractory to at least six months aggressive rehabilitative
Why Are Health Plans Concerned About Spine Surgery?
efforts that include: medical, behavioral health, and
• Most concerned about fusions for DDD
physical therapy interventions. (See Clinical manage-

SYMPOSIA SPINE
• However, also concerned about
ment)
— Nonspecific Low Back Pain
• Findings: (All of the following)
— Spondylolesthesis
— Examination:
— Spinal Stenosis
¬ Waddell sign: less than 3 of 5 positive signs
— Disk Herniation
AND
Why are Health Plans Concerned ? — Radiology:
• The evidence ¬ Evidence that the potentially fused 1 or 2 segment(s)
• The outcomes is/are the generator (s) of the pain
• The cost • Clinical Management:
— At least six months of aggressive rehabilitative efforts that
WHAT DO HEALTH PLANS EXPECT?
includes all of the following:
The Essentials ¬ 1.) Medical; 2.) Behavioral health that includes identi-
• Appropriate non surgical care prior to surgical intervention fication of behavioral health issues and treatment of
• Appropriate care by the appropriate Surgeon in the appro- those issues; 3.) Trial of appropriate pharmaceuticals
priate place of service (NSAIDS); and 4.) Physical therapy/progressive mus-
• Measure and transparently share the outcomes with patients cle strengthening interventions
and public
Appropriate Place of Service
Appropriate Non Surgical Care • Surgical setting in an organization that provides the
• Fear avoidance counseling — Plant
• Medical evaluation for red flags — Equipment
• Biopsychosocial rehabilitation with active physical therapy — Personnel
• Appropriate total care of chronic pain and judicious use of — Efficiency
pain medications — Effectiveness
• Evidence-based use of epidural and other injections and — Safety
modalities — Patient-centered care
• Psychological evaluation of chronic pain patients — Evidence-based practices
• Care teams that include the surgeon — Peer support and review
The Appropriate Surgeon Transparent Measurement
• Training • Standard measurement specifications
• Experience • Infrastructure to support process and outcome measures
• Competence • Willingness to share with health plan, patients and the public
• Collaborate in reviewing comparative data together and
What Does HealthPartners Health Plan Expect?
seek opportunities for improvement
• The Appropriate Surgeon
• Total cost and resource use
— Request for Information
• Thus a value equation
— Training and experience
— Results How Realistic is all of this?
— Team approach • Integrated approach to back pain
— Willingness to collaborate • Preferred networks in PT, Chiro, Injection Therapy, Chronic
— Market-based fees Pain programs, and Fusion Spine Surgeons
• Self-reported Oswestry scores
Appropriate Selection of Patients
• Case Management
• Indications for spinal fusion for DDD as developed by the
• Developing Secondary Specialty Networks
Mpls-St Paul spine surgical community with HPHP
• Patient decision support as well as fully informed consent How Realistic is this?
• Documentation of indications for surgery • Minneapolis and St Paul surgeons have responded to an RFI
process, been selected based on TECO training, experience,
Criteria for Fusion for DDD
competency, and outcomes)
• Symptoms: (All of the following)
• Now engaged in exploring a community-wide study

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
291
SYM 07:Layout 1 1/12/07 11:41 AM Page 292

WHAT IS THE DIAGNOSIS OF DDD?

David W. Polly, Jr., MD

When is DDD pathologic as opposed to an age related What kind of benefit can be achieved by spinal fusion?
change? Adams and Roughley Spine 2006 • BMP FDA IDE studies
• Prospective cohort data
Why is DDD painful?
• RCTs
• Annular fissures, c fiber neural ingrowth from the sinuverte-
SYMPOSIA SPINE

bral nerve and mechanical overload How does this benefit compare to total joint replacement?
(Remarkably similar actually)
When comparing treatment options what is the appropriate
metric? What kind of benefit can be achieved by spinal arthroplasty
• Patient reported outcomes- current standards are Oswestry or other motion sparing devices?
Disability Index (ODI) and SF-36 especially the physical
What is all of the information going on about tech assess-
component subscale (PCS)
ments?
• ODI higher is worse
• Artificial disk and the FDA
• SF-36 PCS higher is better
• Artificial disk and CMS
What is a minimum clinically important difference (MCID)? • Spinal fusion and CMS
• ODI probably 10 points, FDA mandated 15 points • Payors and artificial disks
• SF-36 5.4 points as defined by the developer • Hospitals and new spinal technology

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
292 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 293

ORTHOPAEDIC WAR INJURIES FROM

COMBAT CASUALTY CARE TO DEFINITIVE

SYMPOSIA TRAUMA
TREATMENT: A CURRENT REVIEW OF THE
BASIC SCIENCE, CLINICAL ADVANCES AND
RESEARCH OPPORTUNITIES (AAOS/ORS I)
Co-moderators: Dana C. Covey, MD, San Diego, CA (n) and Roy K. Aaron, MD, Providence, RI

Over 21,000 U.S. service members have been wounded in the ongoing wars in Iraq and
Afghanistan, approximately 70 percent of whom have musculoskeletal injuries, most of
which are caused by exploding ordnance. This symposium will highlight the unique
character of orthopaedic war wounds, treatment challenges on the frontlines and in
subsequent definitive treatment, and basic science advances that may bear on potential
treatment of these often devastating wounds which may also have broad applicability to
trauma resulting from terrorism or natural disasters.

I. Blast Injury: Pathophysiology and Injury Patterns

Christopher T. Born, MD, Providence, RI (n)

II. Battlefield Musculoskeletal Infections; Past, Present, Future.

Jason H. Calhoun, MD, Columbia, MO (n)

III. Evolving Technologies for Enhancement of the Repair of Segmental Bone Defects
Thomas A. Einhorn, MD, Boston, MA (a, e - Stryker, Merck, a - Lilly, e – Novartis)

IV. Advances in Combat Amputee Care

Michael Frisch, MD, Silver Spring, MD (n)

V. New Developments in Soft Tissue Coverage of Massive Wounds

L. Scott Levin, MD, Durham, NC (n)

VI Battlefield Damage Control: Prevention of the Second Hit

Michael T. Mazurek, MD, San Diego, CA (n)

VII. Towards Novel Interventions of Osteomyelitis

Edward Schwarz, PhD, Rochester, NY (a - NIH, MTF, DOD, DePuy, Zimmer, d - LAGeT,
e - Amgen, Centocor, Genzyme)

VIII. The needs and opportunities for pre-clinical orthopaedic trauma research
Joseph C. Wenke, PhD, La Vernia, TX (n)

IX. Aeroevacuation challenges and advances; negative pressure wound management in the
air and the effect of altitude on compartment pressures
Elisha T. Powell IV, MD, Elmendorf, AK (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
293
SYM 07:Layout 1 1/12/07 11:41 AM Page 294

BLAST INJURY: BIODYNAMICS AND INJURY PATTERNS

Christopher T. Born, MD

Much of disaster response has centered on mitigating the effects ondary and tertiary). We have also come to also recognize sev-
of injury not only from natural disasters, but also from the eral quaternary elements.
potential sequelae of terrorist promoted catastrophes involving
Primary blast injury occurs as the shock front and blast wave
nuclear, chemical and biological agents. However, within the
SYMPOSIA TRAUMA

move through the body. Differences in densities of the body’s

current geopolitical environment, explosions and bombings are
anatomical components (particularly at air/fluid interfaces) are
all too commonly the primary disaster “events” to which both
susceptible to spalling, implosion, inertial mismatches as well
civilian and military medical/surgical personnel routinely have
as pressure differentials. Spalling describes the forcible, explo-
to respond. (1) Explosions of overwhelming proportions can
sive movement of fluid from more dense to less dense tissues
also occur outside of the military / political environment.
such as in the lungs. Implosion relates to areas of gas that are
(2)(3)(4)
rapidly compressed at the time of shock front impact and then
Blast injury might be considered as the “fourth weapon of mass rapidly re-expand after it passes causing a rebound expansion
destruction”. In a survey conducted by the Eastern Association with attendant shearing and injury. This is frequently seen in
for the Surgery of Trauma (EAST) of its membership, only 73% the ear/tympanic membrane and intestine. Acceleration/decel-
of the trauma surgeon respondents had an understanding of the eration can cause tearing of organ pedicles and mesentery when
pathophysiology and classification of blast injuries. (5) Out of there is an inertial difference between organ structures. Pressure
necessity, the military has continued to expand its understand- differentials occur wherever there is a liquid/gas interface and
ing and ability to manage blast-related injuries. The civilian incompressible, water filled organs (e.g. vessels) have fluid
medical community remains very unprepared. The purpose of forced into the less compressible adjacent structure.
this section of the program is to improve the surgeon’s familiar-
The most susceptible organs to primary blast injury are the ears,
ity with the pathomechanics and pathophysiology of injury
lungs and gastrointestinal tract. The ears are the most sensitive
from blast and explosion.
organs to blast injury and tympanic membrane rupture can be
Bomb detonation is the rapid chemical transformation of a used as a reliable marker to overpressure exposure. The lungs
solid or liquid into a gas. The gas expands radially outward as are moderately more resistant, but with enough energy exposure
a high-pressure shock wave that exceeds the speed of sound. Air there can be disruption of the capillary-alveolar interface that
is highly compressed on the leading edge of the blast wave cre- leads to parenchymal hemorrhage as well as destruction of the
ating a shock front. The body of the wave, including the associ- alveolar walls. Emphysematous spaces can be created in addi-
ated mass outward movement of air (sometimes called the tion to pneumothorax. The interstitial changes of blast lung can
“blast wind”) follows this front. In an open area, the overpres- lead to Adult Respiratory Distress Syndrome (ARDS). Infiltrates
sure that results generally follows a well-defined pressure/time can be seen on chest X-ray within 90 minutes of the blast. (11)
curve (“Friedlander wave”) with an initial near instantaneous In rare cases, air embolism of the vascular tree is thought to be
spike in the ambient air pressure followed by a longer period of able to lead to sudden death. (12)(13) The gastrointestinal tract
sub-atmospheric pressure. The pressure/time curves can have as a gas filled organ can be injured by implosion and rupture.
variability depending on the local topography, presence of The mucosal wall can become bruised. Shearing injuries can
walls/solid objects and whether the blast is detonated indoors occur caused by acceleration/deceleration relative to more solid,
or outside. The blast wave can reflect off of and flow around adjacent structures. Other organ systems have varying degrees of
solid surfaces. Reflected waves can be magnified 8-9 times caus- response to injury from primary blast and models have been
ing significantly greater injury. (6) (7) Blasts that occur in build- developed to better study the overall pathophysiological effects.
ings and other confined spaces can be more devastating and (6)(14)(15)(16) The lungs tend to be the predominant nonau-
lethal because of the increased energy of the complex and ditory system injured in most air blasts whereas the GI tract is
reflected waves. (8)(9) more susceptible to underwater blasts. Markers are being
sought to better diagnose and treat blast overpressure injury.
The velocity, duration and magnitude of the blast wave’s over-
(7)(17)
pressure are dependent on several factors. These include the
physical size and component explosive of the charge being det- Amputations are not common, but are significant as a marker
onated. High-energy (HE) explosives like TNT and nitroglyc- for a lethal injury when they do occur. These primarily occur
erin are much more powerful than ordinary gunpowder. The through the shaft rather than as disarticulations and are thought
latter tends to produce conflagrations with a higher thermal to be the result of direct coupling of the blast wave into the tis-
output. The medium through which the blast wave moves is sues. Fracture results from axial stress to the long bone and flail-
also a factor. Water with its increased density allows for faster ing of the extremity from the blast wind gas flow completes the
propagation and a longer duration of positive pressure account- amputation (18), although there is some controversy on this.
ing for the increased severity in that environment. The distance (10) Improved knowledge in this are has allowed for the devel-
from the explosion's epicenter also plays a factor with pressure opment of more effective body armor. Amputation infrequent-
wave decay occurring roughly as the inverse cube of the distance. ly results from laceration by projectiles formed secondary to the
(6)(10) blast.
Injury results from three primary components as they interface Secondary blast injury results from the victim being struck by
either directly or indirectly with the victim. These include the missiles that are propagated by the explosion (shrapnel). These
high-pressure shock front and associated blast wave as well as can be intentionally imbedded into the explosive to cause
any thermal components from the detonation. Classically, the wounding. Nails, screws, nuts and bolts seem to be a favorite of
injuries have been divided into three categories (primary, sec- terrorists. Some shrapnel may be a part of the bombs housing
or local material that was made airborne by proximity to the
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
294 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 295

explosion. Glass is common. Most penetrating injuries caused and other blunt injury typically seen in the surviving popula-
by blast driven projectiles should be considered as contaminat- tion.
ed and appropriately prophylaxed with antibiotics and tetanus.
Quaternary injury can come from structural collapse or burns
Small entry holes may be misleading and decisions regarding
secondary to the detonation. Crush, traumatic amputation,
which wounds to explore and debride may be difficult. There
compartment syndromes in addition to other blunt and pene-
have been reported instances of wounding by allogenic bone
trating injuries can be common sequelae of structural collapse.
fragments from suicide terrorists or other victims that have
Flash burns to exposed skin can occur as a result of the thermal
become imbedded in survivors. These cases need to be man-
component of the detonation. Secondary fires can cause addi-
aged specially. (19) (20)

SYMPOSIA TRAUMA
tional burns as well as smoke inhalation.
Tertiary injury stems from the victim’s body being thrown as a
projectile by the blast. This can result in fractures, head trauma

REFERENCES 10. Gans L, Kennedy T. Management of unique clinical entities in disaster medicine.
1. Frykberg ER. Medical management of disasters and mass casualties from terrorist Emergency Medicine Clinics of North America. 1966;14:301-325.
bombings: how can we cope? J Trauma. 2002;53:201-212. 11. Caseby NG, Porter MF. Blast injuries to the lungs: clinical presentation, manage-
2. CBC. The Halifax Explosion. Available at: http://www.cbc.ca/halifaxexplosion/. ment and course. Injury 1976;8:1-12. )
Accessed June 15,2005. 12. Maynard RL, Cooper GJ, Scott R. Mechanism of injury in bomb blasts and explo-
3. National Archives of Canada. Tragedy on the home front: Halifax explosion-6 sions. In Westby S, ed. Trauma-Pathogenesis and Treatment. London:
December, 1917. Available at: http://www.collectionscanada.ca/education/first- Heinemann, 1988: 30-41.
worldwar/05180202/0518020203_e.html. National Archives of Canada, RG 24, 13. Coppel DL. Blast injury of the lungs. Br J Surg 1976;63:735-737.
series D-1-a, vol. 5634, file 37-25-1, part 1. 14. Jönsson A, Arvebo E, Schantz B. Intrathoracic pressure variations in an anthropo-
4. Howell P. The Explosion. Available at: http://www.chron.com/content/chroni- morphic dummy exposed to air blast, blunt impact, and missles. Proceedings,
cle/metropolitan/txcity/index.html. 5th Symposium on Wound Ballistics 1988;28, No.1 Suppl: S135-S131.
5. Ciraulo DL, Frykberg ER, Feliciano DV, et al. A survey assessment of the level of 15. Irwin RJ, Lerner MR, Bealer, et al. Cardiopulmonary physiology of primary blast
preparedness for domestic terrorism and mass casualty incidents among Eastern injury. J Trauma. 1997:43:650-655.
Association for the Surgery of Trauma Members. J Trauma. 2004;56:1033-1041. 16. Stuhmiller JH. Biological response to blast overpressure: a summary of modeling.
6. Hull JB. Blast: injury patterns and their recording. J Audiovisual Media in Med. Toxicology 1997;121:91-103.
1992;15:121-127. 17. Harmon JW, Sampson JA, Graeber GM, et al. Readily available serum markers fail
7. Mayorga MA. The pathology of primary blast overpressure injury. Toxicology to aid in diagnosis of blast injury. J Trauma. 1988;28, No.1 Suppl:S153-S159.
1997;121:17-28. 18. Hull JB, Cooper GJ. Pattern and mechanism of traumatic amputation by explo-
8. Leibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open-air bomb- sive blast. J Trauma. 1996;40:S198-S205.
ings-a comparative study of injuries in survivors of open-air versus confined- 19. Leibner ED, Weil Y, Gross E, et al. A Broken bone without a fracture: traumatic
space explosions. J Trauma. 1996;41:1030-1035. foreign bone implantation resulting from a mass casualty bombing. J Trauma.
9. Katz E, Ofek B, Adler J, et al. Primary blast injury after a bomb explosion in a 2005;58:388-390.
civilian bus. Ann Surg 1988;209:484-488. 20. Boehm T, James JJ: The medical response to the La Belle Disco bombing in
Berlin 1986. Mil Med. 1988;153:235.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
295
SYM 07:Layout 1 1/12/07 11:41 AM Page 296

BATTLEFIELD MUSCULOSKELETAL INFECTIONS:

PAST, PRESENT, FUTURE
Jason H. Calhoun, MD

I. Introduction interoperative infection, and must continue for no more

SYMPOSIA TRAUMA

Through U.S. history, warfare has played a key role in the than 24 hours.
advancement of orthopaedic surgical techniques, including e. Multiple studies demonstrate efficacy of prophylaxis in both
control of extremity wound infections. This presentation open and closed fractures, among multiple trauma patients,
briefly reviews past techniques, describes the present situa- in patients with high-velocity gunshot wounds.
tion in Iraq/Afghanistan, and proposes some future direc- f. Multi-drug resistant organisms and strains of Acinetobacter
tions. baumanii have arisen as a source of concern.
g. A combination of new and old antibiotic strategies will be
II. Past required to address multi-drug resistance. However, many
a. U.S. Civil War: Amputation is primary technique to prevent new agents have a limited or nonexistent track record.
infection. Antiseptic techniques are crude or nonexistent.
Key point: Further research is necessary in choice and timing of
b. World War I: Battlefields were excellent breeding grounds
antibiotics and will be an important collaboration between mil-
for infection. Delayed primary closure replaces amputation
itary/civilian experts.
in many cases. Mortality rates from extremity wounds
decreases. h. Acute infections: Treatment includes debridement, antibi-
c. World War II: Clinical appearance dictates whether wound otics, systemic support, and hyperbaric oxygen therapy.
is ready for closure. Penicillin went into production on a i. Of special concern are clostridial soft tissue infections,
massive scale. More aggressive surgical debridement is streptococcal fasciitis
employed. Mortality rates from extremity wounds decrease j. Chronic infections: To prevent recurrence of infection, the
markedly from World War I. biofilm burden must be excised, and the wound revitalized.
d. Korea, Vietnam: Increasingly versatile and mobile military The health of host, extent of necrotic focus, anatomic site of
levels of care bring wounded to hospitals much more infection, and disability created by the disease are key fac-
quickly, again increasing survivorship and making it possi- tors in setting the course of treatment. The options are sal-
ble for infections to be dealt with earlier. vage, amputation, or suppression.
Key point: As overall military medical care became faster, more IV. Future directions
mobile, infection care and overall survivorship improved. a. A large body of U.S. civilian research has demonstrated the
efficacy of antibiotic prophylaxis in preventing postopera-
III. Present: Iraq/Afghanistan tive infection. Clinical research on combat wounds abroad
a. Improved body armor leads to higher survival rate, decrease may show that antibiotics at injury (incision) are effective.
in lower extremity and torso wounds, increase in head/neck b. More animal studies need to be performed to better inform
and upper extremity wounds. the choice and timing of antibiotic agents. A combination
b. Contamination and soft-tissue trauma from IEDs calls for of old and new antibiotics may ultimately be the most
more aggressive treatments, broad-spectrum antibiotics, promising approach.
debridement. c. New genetics research promises to help caregivers identify
c. Major bacterial agents of concern are Staphylococcus aureus multi-resistant strains and provide treatment.
and Staphylococcus epidermis. d. Future research must focus upon:
1. Data Collection System
Key point: Unique aspects of the current war are driving further
2. Timing of Treatment
innovations and new tactics in preventing and controlling infec-
3. Techniques of Débridement
tion in extremity wounds.
4. Transport Issues
d. Surgical antimicrobial prophylaxis: Should be initiated just 5. Coverage Issues
before an operation begins to reduce microbial burden of 6. New Antibiotic Treatments

REFERENCES 6. Carlsson AK, Lidgren L, Lindberg L. Prophylactic antibiotics against early and late
1. Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther. Oct 29 2001;43(1116- deep infections after total hip replacements. Acta Orthop Scand. 1977;48(4):405-
1117):92-97. 410.

2. ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American 7. Cierny G, DiPasquale D. Treatment of Chronic Infection. J Am Acad Orthop Surg
Society of Health-System Pharmacists. Am J Health Syst Pharm. Sep 15 2006 14: S105-S110.
1999;56(18):1839-1888. 8. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing
3. Boxma H, Broekhuizen T, Patka P, Oosting H. Randomised controlled trial of of prophylactic administration of antibiotics and the risk of surgical-wound
single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the infection. N Engl J Med. Jan 30 1992;326(5):281-286.
Dutch Trauma Trial. Lancet. Apr 27 1996;347(9009):1133-1137. 9. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial pro-
4. Calhoun J, Mader J. Musculoskeletal Infections. New York: Marcel Dekker, Inc.; phylaxis in surgical procedures. The Infectious Diseases Society of America. Infect
2004. Control Hosp Epidemiol. Mar 1994;15(3):182-188.

5. Calhoun JH, Frisch HM. Moderators’ Summary: Antibiotics and Infection. J Am 10. DiPiro JT, Vallner JJ, Bowden TA, Jr., Clark B, Sisley JF. Intraoperative serum con-
Acad Orthop Surg 2006 14: S96-S97. centrations of cefazolin and cefoxitin administered preoperatively at different
times. Clin Pharm. Jan-Feb 1984;3(1):64-67.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
296 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 297

11. Ericson C, Lidgren L, Lindberg L. Cloxacillin in the prophylaxis of postoperative 25. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH.
infections of the hip. J Bone Joint Surg Am. Jun 1973;55(4):808-813, 843. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch
12. Gawande A. Casualties of war--military care for the wounded from Iraq and Surg. Jan 1993;128(1):79-88.
Afghanistan. N Engl J Med. Dec 9 2004;351(24):2471-2475. 26. Patzakis MJ, Harvey JP, Jr., Ivler D. The role of antibiotics in the management of
13. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal open fractures. J Bone Joint Surg Am. Apr 1974;56(3):532-541.
femoral and other closed long bone fractures. Cochrane Database Syst Rev. 27. Place RJ, Rush RM, Jr., Arrington ED. Forward surgical team (FST) workload in a
2001(1):CD000244. special operations environment: the 250th FST in Operation ENDURING FREE-
14. Gross PA, Barrett TL, Dellinger EP, et al. Purpose of quality standards for infec- DOM. Curr Surg. Jul-Aug 2003;60(4):418-422.
tious diseases.Infectious Diseases Society of America. Clin Infect Dis. Mar 28. Pokuski L. Treatment of Acute Infection. J Am Acad Orthop Surg 2006 14: S101-

SYMPOSIA TRAUMA
1994;18(3):421. S104.
15. Gustilo RB. Current concepts in the management of open fractures. Instr Course 29. Pollard JP, Hughes SP, Scott JE, Evans MJ, Benson MK. Antibiotic prophylaxis in
Lect. 1987;36:359-366. total hip replacement. Br Med J. Mar 17 1979;1(6165):707-709.
16. Hanssen AD, Osmon DR, Nelson CL. Prevention of deep periprosthetic joint 30. Rogers C. Military Medicine Wages Its Own War. AAOS Bulletin 2005:52-55.
infection. Instr Course Lect. 1997;46:555-567. 31. Travis MT, Cosio MQ. A retrospective review of orthopedic patients returning
17. Heydemann JS, Nelson CL. Short-term preventive antibiotics. Clin Orthop. Apr from Operations Desert Shield and Desert Storm to an Army Medical Center. Mil
1986(205):184-187. Med. May 1993;158(5):348-351.
18. Holtom PD. Antibiotic Prophylaxis: Current Recommendations. J Am Acad 32. Velmahos GC, Jindal A, Chan L, et al. Prophylactic antibiotics after severe trau-
Orthop Surg 2006 14: S98-S100. ma: more is not better. Int Surg. Jul-Sep 2001;86(3):176-183.
19. Mauerhan DR, Nelson CL, Smith DL, et al. Prophylaxis against infection in total 33. Velmahos GC, Toutouzas KG, Sarkisyan G, et al. Severe trauma is not an excuse
joint arthroplasty. One day of cefuroxime compared with three days of cefazolin. for prolonged antibiotic prophylaxis. Arch Surg. May 2002;137(5):537-541; dis-
J Bone Joint Surg Am. Jan 1994;76(1):39-45. cussion 541-532.
20. Mazurek MT, Fick JR. he Scope of Wounds Encountered in Casualties From the 34. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. Nosocomial infec-
Global War on Terrorism: From the Battlefield to the Tertiary Treatment Facility. J tions in the surgical intensive care unit: a difference between trauma and surgical
Am Acad Orthop Surg 2006 14: S18-S23. patients. Am Surg. Oct 1999;65(10):987-990.
21. Murray CK, Roop SA, Hospenthal DR, et al. Bacteriology of War Wounds at the 35. Wiesel B, Esterhai Jr. J. Prophylaxis of Musculoskeletal Infection. In: Calhoun J,
Time of Injury: Brooke Army Medical Center; 2005. Mader J, eds. Musculoskeletal Infections. New York: Marcel Dekker Inc.;
22. Nelson CL, Green TG, Porter RA, Warren RD. One day versus seven days of pre- 2003:115-129.
ventive antibiotic therapy in orthopedic surgery. Clin Orthop. Jun 36. Williams DN, Gustilo RB, Beverly R, Kind AC. Bone and serum concentrations of
1983(176):258-263. five cephalosporin drugs. Relevance to prophylaxis and treatment in orthopedic
23. Noe, Al. Extremity Injury in War: A Brief History. J Am Acad Orthop Surg 2006 surgery. Clin Orthop. Oct 1983(179):253-265.
14: S1-S6. 37. Yun HC, Murray CK, Roop SA, Hospenthal DR, Gourdine E, Dooley DP. Bacteria
24. Oishi CS, Carrion WV, Hoaglund FT. Use of parenteral prophylactic antibiotics in Recovered from Patients Admitted to a Deployed U.S. Military Hospital in
clean orthopaedic surgery. A review of the literature. Clin Orthop. Nov Baghdad, Iraq: Brooke Army Medical Center, 2005; 2005.
1993(296):249-255.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
297
SYM 07:Layout 1 1/12/07 11:41 AM Page 298

EVOLVING TECHNOLOGIES FOR ENHANCEMENT OF THE REPAIR

OF SEGMENTAL BONE DEFECTS
Thomas A. Einhorn, MD
SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
298 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 299

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
299
SYM 07:Layout 1 1/12/07 11:41 AM Page 300

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
300 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 301

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
301
SYM 07:Layout 1 1/12/07 11:41 AM Page 302

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
302 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 303

NEW DEVELOPMENTS IN SOFT TISSUE COVERAGE OF

MASSIVE WOUNDS
L. Scott Levin, MD

1. Defining the Orthoplastic Approach 5. Soft Tissue Issues in the Amputee

SYMPOSIA TRAUMA
a. Rationale a. Acute (Fillet Flaps, Level Preservation)
b. Implications b. Chronic (Resurfacing)
c. Limb Salvage Rates
6. “New” Flap Techniques
2. Advances in Anatomic Research a. Sural Flap – Pedicle
a. Angiosomes b. “ATLF” – Free
b. Perforator Flaps c. Vascularized Periosteum
3. Integration of Thin Wire Fixation and Soft Tissue
Reconstruction
4. Classification Type I-IV
(Case Examples)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
303
SYM 07:Layout 1 1/12/07 11:41 AM Page 304

BATTLEFIELD DAMAGE CONTROL:

PREVENTION OF THE “SECOND HIT”
Michael Mazurek, MD

I. “Second hit” Models Civilian (Blunt trauma) vs. — Quik Clot

SYMPOSIA TRAUMA

Battlefield (Penetrating) — Heme Con

— Fibrin Sealants
II. Battlefield Stabilization Goals
1. Hemorrage Control IV.Extremity Damage Control
2. Rapid control of life threatening injury 1. Damage Control Orthopaedics
3. Implement treatment modalities that limit chances for • Principles
late mortality (“second hit” prevention) — Advocated for unstable/extremis patients
4. Temporize in a manner that sets up casualty for later — Rapid temporary bony stabilization
treatment success — Revascularization when necessary (Shunts)
— Limit additional physiologic insult
III. Damage Control Surgery
— Avoid immediate definitive surgery
1. Developed as strategy for multivisceral injuries in exsan-
1. Stop the Bleeding
guinating patients. Prevention of a cascade of hypother-
2. Remove the Contamination
mia, acidosis, coagulapothy and eventual multi-system
3. Restore the Blood Flow
organ failure.
4. Stabilize Fractures
• 3 phases
5. No added insults! Set stage for definitive treat-
1. Rapid surgery through large incisions: Control
ment.
hemorrhage, remove contamination, stop progres-
2. Stabilization
sion of visceral injury.
• Benefits
2. Re-warm, correct volume & coagulopathy
— Maintain perfusion
3. Re-explore, definitive repair
— Prevent secondary injury
2. Hypotensive Resuscitation*
— Blunt systemic response
— Clot disruption occurs at BP of 80/-
— Pain control
— Benefits:
— Options in Battlefield Setting; Splints, Traction,
Preserves intravascular volume
External Fixation
Reduces dilutional coagulopathy
3. Revascularization
Reduces hypothermia
• Temporary Vascular Shunting
3. NovaSeven (factor VII)
— Damage control for injured blood vessels
— FDA approved for hemophiliacs
— Placement of silicone tube to bypass injured seg-
— Causes clotting at site of damaged endothelium
ment of vessel(s)
— Adjunct for prevention of hemorrhage secondary to
— Effectively controls hemorrhage
post-traumatic coagulopathy (metabolic derange-
— Rapidly restores blood flow to limb
ments, hypothermia, and depletion or dysfunction of
— Sets stage for definitive graft
cellular and protein components)
4. Antibiotics
— Expensive (effective)
5. Wound Containment
4. Hemostatic Dressings

REFERENCES: 9. Covey DC: Musculoskeletal war wounds during Operation BRAVA in Sri Lanka.
1. Acheson EM, Kheirabadi BS, Deguzman R, Dick EJ, Holcomb JB: Comparison of Milit Med 2004;169: 61-64.
hemorrhage control agents applied to lethal extremity arterial hemorrhages in 10. Eiseman B, Moore EE, Meldrum DR, Raeburn C: Feasibility of damage control
swine. J Trauma 2005;59:865-875. surgery in combat casualties. Arch Surg 2000;135:1323-1327.
2. Alam HB, Chen Z, Jaskille A, et al: Application of a zeolite hemostatic agent 11. Gates JD: The management of combined skeletal and arterial injuries of the
achieves 100% survival in a lethal model of complex groin injury in swine. J lower extremity. Am J Orthop 1995; 24:674-680.
Trauma 2004;56:974-983. 12. Gawande A: Notes of a surgeon: casualties of war - military care for the wound-
3. Alam HB, Burris D, DaCorta JA: Hemorrhage control in the battlefield: role of ed from Iraq and Afghanistan. New Engl J Med 2004;351:2471-2475.
new hemostatic agents. Mil Med 2005;170:63-69. 13. Giannoudis PV. Pape HC. Damage control orthopaedics in unstable pelvic ring
4. Bickell WH, et al. Immediate versus delayed fluid resusitation for hypotensive injuries. Injury. 35(7):671-7, 2004 Jul.
patients with penetrating torso injuries. NEJM 331(17):1105-1109. Oct 1994. 14. Giannoudis, P V. Smith, R M. Bellamy, M C. Morrison, J F. Dickson, R A. Guillou,
5. Botha, A J. Moore, F A. Moore, E E. Kim, F J. Banerjee, A. Peterson, V M.: P J.: Stimulation of the inflammatory system by reamed and unreamed nailing of
Postinjury neutrophil priming and activation: an early vulnerable window. femoral fractures. An analysis of the second hit. Journal of Bone & Joint Surgery -
Surgery. 118(2):358-64; discussion 364-5, 1995 Aug. British. 81(2):356-61, 1999 Mar.
6. Cernak I, Savic J, Ignjatovic D, Jevtic M: Blast injury from explosive munitions. J 15. Hildebrand F, Giannoudis P, Kretteck C, Pape HC: Damage control: extremities.
Trauma 1999; 47:96-103. Injury 2004;35:678-689.
7. Chambers LW. et al. Tactical Surgical Intervention with Temporary Shunting of 16. Holcomb JB. Use of Recombinant activated factor VII to treat the Acquired
Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Coagulapathy of Trauma. Journal of Trauma-Injury Infection & Critical Care.
Unit’s Experience. Journal of Trauma-Injury Infection & Critical Care. 61(4):1155- 58(6):1298-1303, 2005 Jun.
61 2006 Oct. 17. Holcomb JB: Fluid resuscitation in modern combat casualty care: lessons learned
8. Covey DC: Blast and fragment injuries of the musculoskeletal system. J Bone from Somalia. J Trauma 2003;54:S46-S51.
Joint Surg Am 2002;84:1221-1234.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
304 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 305

18. Holcomb JB: Standard operating procedure for use of recombinant factor VIIa 30. Pape, HC. Grimme, K. Van Griensven, M. Sott, A H. Giannoudis, P. Morley, J.
(rFVIIa). U.S. Army Institute of Surgical Research memo MCMR-USZ-B, 1 May Roise, Olav. Ellingsen, Elisabeth. Hildebrand, Frank. Wiese, B. Krettek, Christian.
2004. EPOFF Study Group.: Impact of intramedullary instrumentation versus damage
19. Holcomb JB: The 2004 Fitts lecture: current perspective on combat casualty care. control for femoral fractures on immunoinflammatory parameters: prospective
J Trauma 2005; 59:990-1002 randomized analysis by the EPOFF Study Group. Journal of Trauma-Injury
Infection & Critical Care. 54(4):203-9, 2002 Nov.
20. Kenet G, et al. Treatment of traumatic bleeding with recombinant factor VIIa.
Lancet 354:1870 1999. 31. Pape, H C. van Griensven, M. Rice, J. Gansslen, A. Hildebrand, F. Zech, S. Winny,
M. Lichtinghagen, R. Krettek, C.: Major secondary surgery in blunt trauma
21. Lerner, A. Chezar, A. Haddad, M. Kaufman, H. Rozen, N. Stein, H.: patients and perioperative cytokine liberation: determination of the clinical rele-
Complications encountered while using thin-wire-hybrid-external fixation mod- vance of biochemical markers. Journal of Trauma-Injury Infection & Critical

SYMPOSIA TRAUMA
ular frames for fracture fixation. A retrospective clinical analysis and possible Care. 50(6):989-1000, 2001 Jun.
support for "Damage Control Orthopaedic Surgery". Injury. 36(5):590-8, 2005
May. 32. Pusateri AE, McCarthy SJ, Gregory KW, et al: The effect of a chitosan-based
hemostatic dressing on blood loss and survival in a model of severe venous
22. Lynn M. Jeroukhimov I. Klein Y. Martinowitz U. Updates in the management of hemorrhage and hepatic injury in swine. J Trauma 2003;54:177-182.
severe coagulopathy in trauma patients. Intensive Care Medicine. 28 Suppl
2:S241-7, 2002 Oct. 33. Pusateri AE, Delgado AV, Dick EJ, Martinez RS, Holcomb JB, Ryan KL:
Application of a granular mineral-based hemostatic agent (QuikClot) to reduce
23. Martinowitz U. Zaarur M. Yaron BL. Blumenfeld A. Martonovits G. Treating trau- blood loss after grade V liver injury in swine. J Trauma 2004;57:555-562.
matic bleeding in a combat setting: possible role of recombinant activated factor
VII. Military Medicine. 169(12 Suppl):16-8, 4, 2004 Dec. 34. Przkora R. Bosch U. Zelle B. Panzica M. Garapati R. Krettek C. Pape HC. Damage
control orthopedics: a case report. Journal of Trauma-Injury Infection & Critical
24. Martinowitz U. Kenet G. Segal E. Luboshitz J. Lubetsky A. Ingerslev J. Lynn M. Care. 53(4):765-9, 2002 Oct.
Recombinant activated factor VII for adjunctive hemorrhage control in trauma.
Journal of Trauma-Injury Infection & Critical Care. 51(3):431-8; discussion 438- 35. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an approach
9, 2001 Sep. for improved survival in exsanguinating penetrating abdominal injuries. J
Trauma. 1993; 35: 375–382.
25. Martinowitz U. Kenet G. Lubetski A. Luboshitz J. Segal E. Possible role of recom-
binant activated factor VII (rFVIIa) in the control of hemorrhage associated with 36. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to
massive trauma. Canadian Journal of Anaesthesia. 49(10):S15-20, 2002 Dec. intramedullary nailing for patients with multiple injuries and with femur frac-
tures: damage control orthopedics. J Trauma. 2000;48:613-623.
26. Ogura, H. Tanaka, H. Koh, T. Hashiguchi, N. Kuwagata, Y. Hosotsubo, H.
Shimazu, T. Sugimoto, H.: Priming, second-hit priming, and apoptosis in leuko- 37. Sondeen JL, Coppes VG, Holcomb JB: Blood pressure at which rebleeding occurs
cytes from trauma patients. Journal of Trauma-Injury Infection & Critical Care. after resuscitation in swine with aortic injury. J Trauma 2003;54:S110-S117.
46(5):774-81; discussion 781-3, 1999 May. 38. van Griensven, M. Kuzu, M. Breddin, M. Bottcher, F. Krettek, C. Pape, HC.
27. Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open Tschernig, T.: Polymicrobial sepsis induces organ changes due to granulocyte
fractures. A review of 1085 consecutive cases. J Bone Joint Surg Br 1995; 77:93- adhesion in a murine two hit model of trauma. Experimental & Toxicologic
97. Pathology. 54(3):203-9, 2002 Nov.

28. Pape HC, van Griensven M, Sott AH, et al. Impact of intramedullary instrumen- 39. Walters TJ, et al. Effectiveness of Self Applied Tourniquets in Human Volounteers.
tation versus damage control for femoral fractures on immunoinflammatory Prehospital Emergency Care. 9(4):416-422 Oct/Dec 2005.
parameters: prospective randomized analysis by the EPOFF study group. J 40. White, T O. Clutton, R E. Salter, D. Swann, D. Christie, J. Robinson, C M.: The
Trauma. 2003;55:7-13 early response to major trauma and intramedullary nailing. J Bone Joint Surg Br
29. Pape HC, Giannoudis P, Kretteck C: The timing of fracture treatment in polytrau- 2006; 88:823-7.
ma patients: relevance of damage control orthopaedic surgery. Am J Surg
2002;183:622-629.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
305
SYM 07:Layout 1 1/12/07 11:41 AM Page 306

TOWARDS NOVEL INTERVENTIONS OF OSTEOMYELITIS

Edward Schwarz, PhD
SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
306 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 307

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
307
SYM 07:Layout 1 1/12/07 11:41 AM Page 308

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
308 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 309

ORTHOPAEDIC WAR INJURIES FROM COMBAT CASUALTY CARE TO

DEFINITIVE TREATMENT: A CURRENT REVIEW OF THE BASIC
SCIENCE, CLINICAL ADVANCES AND RESEARCH OPPORTUNITIES
Elisha T. Powell IV, MD

SYMPOSIA TRAUMA
Aeroevacuation Challenges and Advances: reinforcing saturated wound dressings. Furthermore, by
• Negative pressure wound management in the air initiating this wound therapy at Level II and III Medical
• The Challenge of Compartment Syndromes in the Treatment Facilities close to the battlefield, wounds may
Aeromedical Transport System be able to be definitively closed more quickly at the Level
• DVT update IV facility in Germany (Landstuhl Regional Medical
Center) and Level V facilities in the United States poten-
Overview:
tially shortening hospital stay and overall recovery time.
Injured and ill patients are being moved out of the combat zone
much faster than 10 to 15 years ago. The average time for II. The Challenge of Compartment Syndrome Management
patients to be transported to Germany and on to the United in the Aeromedical Transport System
States has decreased from 10-14 days during Operation Desert A. Extremity compartment syndromes as we transport
Storm, to 3 days. The doctrine has changed from stable patient injured patients rapidly to Germany and back to the
care to critical patient care… move sicker patients sooner rather United States has been identified as an issue. Patients
than holding them in hospitals near or in the combat zone. arrive back in Germany and the United States as soon as
Critical Care Air Transport Teams (CCATT) have been a huge 24 to 72 hours post-injury.
factor with increased critical care patient movement. New B. This cohort represents a very physically fit group of
advances, as well as challenges, have arisen from this revolu- patients prior to injury who are now extremely ill as a
tionary change in how we transport and care for patients result of very high energy injuries.
through the aeromedical evacuation system. C. Over 2,000 patients with traumatic injuries to the
extremities retrospectively evaluated at Landstuhl
• 38,411 Patients Moved Since 10 Oct 2001 to 3 Dec 2006
Regional Medical Center over an 18 month period. Of
— 7,588 Battle Injuries
those patients, 275 required an extremity fasciotomy dur-
— 1,795 Patients with Battle Injuries Transported in the
ing the first 3 days in Iraq, Afghanistan, or on arrival in
Aeromedical Evacuation System in FY06 from Iraq or
Germany. Some of these fasciotomies were not per-
Afghanistan to Germany
formed until arrival at Landstuhl; certain % had muscle
I. Negative pressure wound management in the air necrosis and long term morbidity.
A. Negative pressure wound therapy has revolutionized the D. Twenty one patients underwent primary fasciotomy at
treatment of soft tissue wounds resulting from both trau- Landstuhl Regional Medical Center (LRMC) Jan-Jun
matic and non-traumatic causes. Treatment has been 2006; none met usual criteria for prophylactic fasciotomy
demonstrated to augment wound granulation and heal- in Iraq or Afghanistan, but some developed complica-
ing, to promote wound contraction, control wound tions.
secretions, decrease wound edema, reduce skin macera-
Life-threatening complications:
tion, and improve pain management.
• 5 had/developed ARDS/Inhalation injury (24%)
B. Due to aeromedical limitations and other concerns, neg-
• 6 developed Acute Renal Insufficiency/Failure (29%)
ative pressure wound therapy has not been routinely
• 1 death (5%)
applied in the management of soft tissue wounds prior
to casualty arrival in the US. Ongoing experience using 67% met > 3 of 4 criteria:
negative pressure wound therapy on the traumatic • IED blast as Mechanism of Injury
wounds of Iraqi nationals in theater has reproduced • Extremity Injury
many of the previously mentioned benefits. • > 5 liters crystalloid resuscitation
C. A commercially produced wound system has completed — > 5 units FFP transfused
air worthiness testing by Air Mobility Command and is E. Some combination of the following 4 criteria (IED blast,
now available for use within the aeromedical evacuation Extremity injury, > 5 liters crystalloid resuscitation and/or
system. > 5 units FFP transfused) in conjunction with aspects of
D. A feasibility study is now underway in the United States the Air Evacuation process (IV fluid rates, litter immobili-
Air Force aeromedical evacuation system. If proven to be ty, relative decrease in ambient oxygen, relative decrease
safe and feasible, early negative pressure wound therapy in humidity, vibration, cabin pressure at altitude, etc)
for selected soft tissue wounds in US casualties using may lead to the occult development/evolution of extrem-
appropriate equipment and trained medical support may ity compartment syndrome which can cause life-threat-
improve outcomes. The utilization of the transportable ening complications.
negative pressure wound system during aeromedical F. As a result, new Clinical Practice Guideline developed in
evacuation has the potential to improve pain manage- Fall 2005 by the Joint Theater Trauma System Director
ment, facilitate wound healing, and simplify in-flight (Col. Don Jenkins, MD) for compartment syndrome
wound care management. management (this guideline is not a substitute for clini-
E. Specifically, medical attendants may be able to dispense cal judgment):
fewer medications to these patients and spend less time

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
309
SYM 07:Layout 1 1/12/07 11:41 AM Page 310

— All patients not undergoing in-theater fasciotomy for is being accomplished by the Joint Theater Trauma
some other reason who meet 3 or more of the follow- System team.
ing criteria (extremity injury, IED MOI, 5 liters or
III. Deep Vein Thrombosis in the Aeromedical Transport
more crystalloid in 24 hours or 5 units FFP) should
System:
be closely monitored for development of compart-
A. Blast injury seen in theater today is a unique injury
ment syndrome for 48 or more hours, possibly in the
mechanism not often seen in the civilian environment.
combat theater prior to aeromedical transport. Is
High-explosive (HE) blast effect may cause increased risk
rapid aeromedical evacuation the 5th factor leading to
of DVT/PE formation in combat casualties.
the development of occult compartment syndrome?
SYMPOSIA TRAUMA

B. There is an increasing recognition of DVT in individuals

Will these compartment syndromes occur as the
who complete an extended period of travel on an air-
injury evolves/progresses in the first 24 to 72 hours
plane. One study noted a 10% prevalence of asympto-
post-blast/thermal/penetrating injury with or without
matic DVT in individuals undergoing flights of 8 hours
rapid aeromedical transport?
or more.
— This is an acutely ill patient population with very high
C. Because of the short aeromedical evacuation times
morbidity and mortality. Many of these patients can-
achievable in our system today, it may be possible that
not tolerate a prophylactic fasciotomy due to instabili-
certain patients will still be receiving blood product ther-
ty and coagulopathy. This group needs monitoring for
apy to correct coagulopathy when they enter the chain. It
development not only of compartment syndrome but
is inherent on providers at each step in the aeromedical
for development of these acute life-threatening com-
evacuation chain to evaluate patients for DVT prophylax-
plications.
is and make adjustments in therapy as clinically appro-
— Consider compartment pressure monitoring (one
priate. It is recommended to begin DVT prophylaxis ther-
approach is to use differential pressure between the
apy as soon as coagulopathy is corrected in patients not
diastolic blood pressure and the measured compart-
otherwise at increased risk of bleeding.
ment pressure: any pressure difference less than 30
D. The problem often times precedes entry into the AE sys-
mm Hg could be the threshold)
tem. No real data exists on AE-system related stressors
— No elevation of injured extremity.
which may exacerbate DVT/PE rates other than immobil-
— During this monitoring period, any patient who
ity (accelerative/decelerative forces, lower ambient oxy-
meets typical criteria for fasciotomy (develops classic
gen tension, dehydration, vibration, immobility for
signs/symptoms of compartment syndrome) or pro-
extended periods during AE process, elevation in throm-
phylactic fasciotomy (rising compartment pressures or
bin-antithrombin complex, etc) which may not affect
other clinical suspicion) should have fasciotomy per-
patients in the regular hospital setting but do affect the
formed at the earliest possible opportunity.
combat casualty in our echelons of care system.
— Patients receiving escharotomies of below-knee or
E. The Joint Theater Trauma System (JTTS) staff has devel-
elbow should also receive prophylactic fasciotomy.
oped a clinical practice guideline for patients at highest
— Once fasciotomy is done, patient should be evacuated
risk to include those undergoing emergency trauma sur-
as soon as feasible.
gical procedures with major orthopedic surgery/injuries
— Operational considerations may preclude the hold-
of the extremities, spine, and pelvis, and those with
ing/monitoring of patients; clinicians must carefully
ongoing coagulopathy or with a prohibitive risk of
weigh the risk of prophylactic fasciotomy (bleeding,
bleeding. Lovenox, Sequential Compression Devices, and
further instability, etc) against the risk of compart-
IVC filters are all options with the guideline.
ment syndrome.
F. No pulmonary emboli have been seen in patients at
G. Any FASCIOTOMY done, whether affiliated with this
Landstuhl Regional Medical Center since protocol has
protocol or not, whether prophylactic or therapeutic,
been instituted.
should ALWAYS BE DONE COMPLETELY; the very same
G. Recent pneumatic/sequential compression device failed
factors that lead to performance of fasciotomy in the first
flight testing at Air Mobility Command. No SCD type
place are still present and incomplete fasciotomies
device currently approved for flight. Testing continues
(missed compartment or incomplete longitudinal open-
and is ongoing. SCD’s are in use at all Level III facilities
ing of fascia and/or skin) have led to development of
in the combat zone.
acute compartment syndrome and similar complications.
H. DVT and PE can be prevented in 90% or more of surgical
H. Performance improvement tracking of patients meeting
and trauma patients without additional risk factors by
the criteria of this protocol, compliance with this proto-
use of a systematic preventive strategy.
col and outcomes of patients managed by this protocol

REFERENCES: 5. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound
1. Venturi ML, Attinger CE, Meshabi AN, et al. Mechanisms and clinical applica- control and treatment: clinical experience. Ann Plast Surg 1997; 38(6): 563-577
tions of the vacuum-assisted closure (VAC) device. Am J Clin Dermatol 2005; 6. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuum-assisted closure
6(3): 185-194 therapy for the treatment of lower-extremity wounds with exposed bone. Plast
2. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy Reconstr Surg 2001 Oct; 108(5): 1184-1191
to treat hematomas and surgical incisions following high energy trauma. J 7. Joseph, E, Hamori, CA, Bergman, S., et al. A prospective randomized trial of vac-
Trauma 2006; 60(6): 1301-1306 uum-assisted closure versus standard therapy of chronic nonhealing wounds.
3. Herscovici D, Sanders RW, Scaduto JM et al. Vacuum-assisted wound closure Wounds 2000; 12(3): 60-67
(VAC Therapy) for the management of patients with high energy soft tissue 8. Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C. Experience with
injuries. J Ortho Trauma 2003; 17(10): 683-688 wound vac and delayed primary closure of contaminated soft tissue injuries in
4. Miller Q, Bird E, Bird K, et al. Effect of subatmospheric pressure on the acute Iraq. J Trauma 2006 Nov; 61 (5): 1207-11
healing wound. Current Surgery 2004; 61(2): 204-208 9. Kirby JP, Fantus RJ, Ward S, Sanchez O, Walker E, Mellett MM, et al. Novel uses
of a negative-pressure wound care system. J Trauma 2002 Jul; 53(1): 117-21

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
310 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 311

10. Schreijer AJM, Cannegieter SC, Meijers CM, Middeldorp S, et al. Activation of 14. Wightman J. Blast Injuries: Recognition and Management. Operational Medicine
coagulation system during air travel: a crossover study. Lancet 2006; 367: 832-38 2001,
11. Scurr JH; Machin SJ; Bailey-King S; Mackie IJ; McDonald S; Smith PD. Frequency 15. Sing RF, Camp SM et al. Timing of Pulmonary Emboli after Trauma: Implications
and prevention of symptom-less deep venous thrombosis in long haul flights: a for Retrievable Vena Cava Filters. J Trauma 2006; 60: 732-735
randomized trial. Lancet 2001; 357: 1485-9 16. Cook D, et al. Deep Venous Thrombosis in medical-surgical critically ill patients;
12. Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboem- prevalence, incidence and risk factors. Crit Care Med 2005; 33:1565-1571
bolism in trauma patients. J Trauma 1994; 37: 480-7 17. Bagg MR, Covey DC, Powell ET. Levels of medical care in the global war on ter-
13. Geerts WH, Code KJ, Jay RM, et al. A prospective study of venous thromboem- rorism. J Am Acad Orthop Surg 2006; 14:S7-S9
bolism after major trauma. N Engl J Med 1994; 331: 1601-6 DISCLAIMER: The views expressed in this presentation are those of the speakers and do not

SYMPOSIA TRAUMA
represent those of the Armed Services, the Department of Defense or the U.S. Government.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
311
SYM 07:Layout 1 1/12/07 11:41 AM Page 312

◆ CHANGING FACE OF
ORTHOPAEDIC TRAUMA (S)
SYMPOSIA TRAUMA

Moderator: Nirmal C. Tejwani, MD, New York, NY (a - Zimmer, Stryker, EBI)

This symposium will focus on newer techniques, tricks and implants needed to manage
injuries sustained in the obese, in the elderly and in high-energy fractures.

I. Introduction
Nirmal C. Tejwani, MD, New York, NY (a - Zimmer, Stryker, EBI)

II. Impact of Obesity on trauma care and outcomes

Alan L. Jones, MD, Dallas, TX (a - Synthes America)

III. Peri-prosthetic fractures and other fragility fractures

Andrew H. Schmidt, MD, Plymouth, MN (a - Synthes USA, d - Twin Star Medical,
e – Smith & Nephew, DePuy)

IV. Use of locking implants in fracture management. Pros and Cons.

Philip R Wolinsky, MD, Sacramento, CA (a - Synthes, Stryker, Depuy)

V. Minimally Invasive techniques in fracture fixation.

Nirmal Tejwani, MD, New York, NY (a - Zimmer, Stryker, EBI)

VI. Use of BMPs and other modalities in the treatment of non-unions.

Jeffery M. Smith, MD, San Diego, CA (e - Smith& Nephew, e - Stryker)

VII. Question and Answers and Case Presentations

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
312 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 313

CHANGING FACE OF ORTHOPAEDIC TRAUMA.

MINIMALLY INVASIVE TECHNIQUES.
Nirmal C. Tejwani, MD

Percutaneous or Minimally Invasive techniques have trans- Percutaneous or minimally invasive techniques may be used for

SYMPOSIA TRAUMA
formed surgical indications and patient care especially with almost all peri-articular fractures and other injuries like proxi-
high-energy soft tissue trauma. Over the course of last few years mal femur or humerus fractures. We have adopted to use of
there has been increased use of these biological methods as a these techniques even for nailing long bone fractures, using sig-
way to minimize iatrogenic surgical trauma, decrease significant nificantly smaller incisions than traditionally used.
blood loss and avoid disruption of fracture biology associated
with traditional open approaches. Newer implants have facili- Biology
tated this with pre-contoured plates and instruments designed
Implants
for fracture reduction and percutaneous implant placement.
Biological internal fixation does not compromise the restora- Technique
tion of early and complete function of the limb, while still
Discussion
allowing painless function and reliable healing.
Fracture anatomy is also better understood with use of 3D CT
Scans and MRI, leading to increased fracture understanding and
care without exposing the whole fracture area.

REFERENCES 7. Chong, K.W., et al., The use of computer navigation in performing minimally
1. Alvarez, L., et al., Percutaneous vertebroplasty: functional improvement in invasive surgery for intertrochanteric hip fractures--The experience in Singapore.
patients with osteoporotic compression fractures. Spine, 2006. 31(10): p. 1113-8 Injury, 2006. 37(8): p. 755-62.

2. Apivatthakakul, T., O. Arpornchayanon, and S. Bavornratanavech, Minimally 8. Kregor, P.J., et al., Treatment of distal femur fractures using the less invasive stabi-
invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? lization system: surgical experience and early clinical results in 103 fractures. J
A cadaveric study and preliminary report. Injury, 2005. 36(4): p. 530-8. Orthop Trauma, 2004. 18(8): p. 509-20.

3. Alobaid, A., et al., Minimally invasive dynamic hip screw: prospective random- 9. Krettek, C., et al., Intraoperative control of axes, rotation and length in femoral
ized trial of two techniques of insertion of a standard dynamic fixation device. J and tibial fractures. Technical note. Injury, 1998. 29 Suppl 3: p. C29-39.
Orthop Trauma, 2004. 18(4): p. 207-12. 10. Stannard, J.P., et al., The less invasive stabilization system in the treatment of
4. Brandt, S.E., et al., Percutaneous compression plating (PCCP) versus the dynamic complex fractures of the tibial plateau: short-term results. J Orthop Trauma,
hip screw for pertrochanteric hip fractures: preliminary results. Injury, 2002. 2004. 18(8): p. 552-8.
33(5): p. 413-8. 11. Truumees, E., A. Hilibrand, and A.R. Vaccaro, Percutaneous vertebral augmenta-
5. Cole, P.A., M. Zlowodzki, and P.J. Kregor, Treatment of proximal tibia fractures tion. Spine J, 2004. 4(2): p. 218-29.
using the less invasive stabilization system: surgical experience and early clinical 12. Talarico, L.M., G.R. Vito, and S.Y. Zyryanov, Management of displaced intraarticu-
results in 77 fractures. J Orthop Trauma, 2004. 18(8): p. 528-35. lar calcaneal fractures by using external ring fixation, minimally invasive open
6. Crowl, A.C. and D.M. Kahler, Closed reduction and percutaneous fixation of reduction, and early weightbearing. J Foot Ankle Surg, 2004. 43(1): p. 43-50.
anterior column acetabular fractures. Comput Aided Surg, 2002. 7(3): p. 169-78. 13. Tonetti, J., et al., Percutaneous iliosacral screw placement using image guided
techniques. Clin Orthop Relat Res, 1998(354): p. 103-10.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
313
SYM 07:Layout 1 1/12/07 11:41 AM Page 314

PERIPROSTHETIC FRACTURES
Andrew H. Schmidt

General Principles Postoperative femoral periprosthetic fracture is an uncommon

1) Consider these fractures to be in osteoporotic bone. complication of total hip arthroplasty surgery, but several cen-
2) If associated implant loose, they may best treated by revi- ters worldwide have recently reported an increase in total num-
sion arthroplasty. bers of such fractures. This severe complication is costly for soci-
SYMPOSIA TRAUMA

3) When treating with ORIF, protect the entire bone and used ety and results in high morbidity. Our analysis of 1049 peripros-
fixed-angle fixation. thetic fractures occurring in Sweden between 1979 and 2000
and recorded in the Swedish National Hip Arthroplasty Register
Acetabular Fractures – THA
focuses on patient- and implant-related factors, fracture classifi-
• Intraoperative fractures usually occur during placement of
cation, and fracture frequency. These were our 3 major findings:
an uncemented cup.
(1) a majority of the patients who sustained a late periprosthet-
• Late postop fractures associated with pelvic osteolysis and
ic femoral fracture had a loose stem. (2) Implant-related factors
trauma.
are significantly associated with occurrence of a periprosthetic
• Reconstruct using standard approaches to repair the anterior
fracture. (3) Since the 1980s in Sweden, treatment results for
and posterior columns first , then use an uncemented revi-
periprosthetic fractures have been poor, with low long-term sur-
sion stem.
vivorship and a high frequency of complications. We have initi-
• Consider a staged approach for those with severe bone loss
ated further studies of this important problem.
or if infection is suspected.
Periprosthetic fracture of the femur is an uncommon complica-
Femoral Fractures – THA
tion after total hip replacement, but appears to be increasing. We
• Classified using the Vancouver system, which directs treat-
undertook a nationwide observational study to determine the
ment.
risk factors for failure after treatment of these fractures, examin-
• Fractures at the tip of a stable stem are the dilemma:
ing patient- and implant-related factors, the classification of the
— When treated with ORIF (the recommended approach),
fractures and the outcome. Between 1979 and 2000, 1049
the unions rates are 70 – 80 %
periprosthetic fractures of the femur were reported to the
— When treated with long-stem revision, the success rates
Swedish National Hip Arthroplasty Register. Of these, 245 had a
are 90-100%
further operation after failure of their initial management. Data
— Many may be associated with loose stems that appear
were collected from the Register and hospital records. The mate-
stable.
rial was analysed by the use of Poisson regression models. It was
• When plating, use the entire bone and use a fixed-angle
found that the risk of failure of treatment was reduced for
implant at the knee to prevent a later supracondylar frac-
Vancouver type B2 injuries (p = 0.0053) if revision of the implant
ture.
was undertaken (p = 0.0033) or revision and open reduction and
• The use of strut grafts is common but may not be routinely
internal fixation (p = 0.0039) were performed. Fractures classi-
necessary
fied as Vancouver type B1 had a significantly higher risk of fail-
• The use of BMP’s is attractive but untested.
ure (p = 0.0001). The strongest negative factor was the use of a
Femoral Fractures – TKA single plate for fixation (p = 0.001). The most common reasons
• Traditional options are plating vs. retrograde nail. for failure in this group were loosening of the femoral prosthe-
• The introduction of locked plating has really made retro- sis, nonunion and re-fracture. It is probable that many fractures
grade nails unnecessary and locked plates should be consid- classified as Vancouver type B1 (n = 304), were in reality type B2
ered the method of choice. fractures with a loose stem which were not recognised. Plate fix-
• Again, plate long to avoid a secondary fracture. ation was inadequate in these cases. The difficulty in separating
type B1 from type B2 fractures suggests that the prosthesis
Introduction: Periprosthetic fractures of the femur present a
should be considered as loose until proven otherwise.
challenging surgical problem. The aim of this study was to ret-
rospectively evaluate the outcome of periprosthetic fractures sta- Management of periprosthetic fractures around the knee is often
bilised with an angular stable, less invasive stabilisation system difficult because of poor bone quality, comminution, and con-
(LISS). Patients and methods: Thirteen patients (ten total hip-, straints imposed by the existing prosthesis. Locked condylar
two total knee-, one total hip- and knee-arthroplasty) with plates may provide more reliable fixation for these fractures
periprosthetic fractures were treated with the LISS internal fixa- than traditional methods of fixation. Eleven patients with
tor (in ten cases minimal invasive). Six patients had previous periprosthetic fractures around the knee were treated with open
operations due to periprosthetic fractures. The average follow- reduction and internal fixation using a locked condylar plate.
up period was 20 months, follow-up rate 85%. Results: All frac- All 9 acute fractures and 1 of 2 periprosthetic nonunions healed
tures showed radiographic fracture healing without implant at an average of 21 weeks, and no patient required additional
loosening. Except one patient, all patients had returned to their surgery. Nine fractures healed in anatomical alignment, where-
pre-operative activity level. No early post-operative complica- as 1 healed in 5 degrees valgus. The remaining periprosthetic
tions were seen. There was one implant failure after 4 months nonunion developed a persistent nonunion with subsequent
and two cases of malunion. Conclusion: The cases showed the hardware failure. The average range of motion was 4 degrees to
internal fixator to be effective for the stabilisation of peripros- 92 degrees . Locked plating systems are highly effective for the
thetic fractures, even in cases of poor bone quality with good management of complex periprosthetic fractures around the
functional outcomes. The internal fixator, with the option of knee. They result in reliable fracture healing and permit early
minimal invasive application, is the preferred method of motion in complex fractures.
osteosynthesis in periprosthetic fractures.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
314 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 315

BACKGROUND: The application of indirect reduction tech- average of twenty-four months. RESULTS: All fractures healed in
niques has improved fracture-healing and reduced the need for satisfactory alignment at an average of twelve weeks (range, seven
bone-grafting compared with the outcomes of older, direct to twenty-three weeks) after the index procedure. One patient
reduction techniques. We investigated the results of such indirect had one fractured cable and two others had one fractured screw,
reduction techniques for the treatment of periprosthetic femoral but all of the fractures healed without evidence of implant loos-
shaft fractures. METHODS: Fifty consecutive patients with a ening or malalignment. There was one deep infection in the peri-
femoral shaft fracture about a stable intramedullary implant (a operative period. Thirty of the forty-one patients returned to
Vancouver Type-B1 fracture) were treated with a protocol that their baseline ambulatory status. CONCLUSIONS: The results of
included open reduction with use of indirect reduction tech- this study support the use of indirect open reduction and inter-

SYMPOSIA TRAUMA
niques and internal fixation with a single lateral plate without nal fixation with a single extraperiosteal lateral plate, without the
structural allografting or other bone-grafting. Four patients died use of allograft struts, for the treatment of a femoral shaft fracture
in the early postoperative period, and five had inadequate fol- about a stable intramedullary implant. LEVEL OF EVIDENCE:
low-up. The remaining forty-one patients (average age, seventy- Therapeutic Level IV.
two years) were evaluated clinically and radiographically at an

REFERENCES 3. Lindahl H, Malchau H, Oden A, et al. Risk factors for failure after treatment of a
1. Kaab MJ, Stockle U, Schutz M, et al. Stabilisation of periprosthetic fractures with periprosthetic fracture of the femur. J Bone Joint Surg Br. 2006;88(1) p26-30
angular stable internal fixation: a report of 13 cases. Arch Orthop Trauma Surg 4. Raab GE, Davis CM. Early healing with locked condylar plating of periprosthetic
2006;126(2) p105-10. fractures around the knee. J Arthroplasty. 2005;20(8) p984-9
2. Lindahl H, Malchau H, Herberts P, et al. Periprosthetic femoral fractures classifi- 5. Ricci WM, Bolhofner BR, Loftus T, et al. Indirect reduction and plate fixation,
cation and demographics of 1049 periprosthetic femoral fractures from the without grafting, for periprosthetic femoral shaft fractures about a stable
Swedish National Hip Arthroplasty Register. J Arthroplasty. 2005;20(7) p857-65 intramedullary implant. J Bone Joint Surg Am. 2005; 87(10) p2240-5

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
315
SYM 07:Layout 1 1/12/07 11:41 AM Page 316

LOCKED PLATING
Philip Wolinsky, MD

Biomechanics of locked plating Cost

• Current Indications/ uses: • What’s new?
— Osteopenia — Poly axial plates
— Short segments — Effect of cross threading screws
SYMPOSIA TRAUMA

— Percutaneous plating (guides, etc) — Bicortical or unicortical diaphyseal screws for osteoporot-
— Two column metaphyseal fractures: ic bone
¬ Distal radius, distal femur, proximal tibia, distal tibia — Hybrid fixation
— Effect of improper plate position

REFERENCES 12. Gosling T, Schadelmaier P, Muller M. Single locked screw plating of Bicondylar
1. Curtis R, Goldhahn J, Schwyn R, et al. Fixation principles in metaphyseal bone- a tibial plateau fractures. CORR 439, 2005: 207-214
patent based review. Osteoporosis Int 16, 2005: S54-64 13. Haidukewych G. Innovation in locking plate technology. JAAOS 12(4), 2004:
2. Egol K, Kubiak E, Fulferson E, et al. Biomechanics of locked plates and screws. 205-212
JOT 18(8), 2004: 488-493 14. Korner J, Diederichs G, Arzorf M, et al. A biomechanical evaluation of methods
3. Egol K, Su E, Tejwani N, et al. Treatment of complex tibial plateau fractures using of distal humerus fracture fixation using locking compression plates versus con-
the LISS plate: clinical experience and a laboratory comparison with double plat- ventional reconstruction plates. JOT 18(5), 2004: 286-293
ing. J Trauma 57, 2004: 340-346 15. Perren S. Evolution and rationale of locked internal fixator technology introduc-
4. Ellis T, Bourgeault C, Kyle R. Screw position affects dynamic compression plate tory remarks. Injury 32, 2001: SB3-9
strain in an in vitro fracture model. JOT 15(5), 2001: 333-337 16. Perren S. Evolution of the internal fixation of long bone fractures. JBJS(B), 84(8),
5. ElMaraghy A, ElMaraghy M, Nousiainen M, et al. Influence of the number of cor- 2002: 1093-1110
tices on the stiffness of plate fixation of diaphyseal fractures. JOT 15(3), 2001: 17. Raab G, Davis C. Early healing with locked condylar plating of periprosthetic
186-191 fractures around the knee. J Arthroplasty 20(8), 2005: 984-989
6. Frigg R. Locking compression plate (LCP). An osteosynthesis plate based on the 18. Ricci W, Loftus T, Cox C, et al. Locked plates combined with minimally invasive
dynamic compression plate and point contact fixator. Injury 32, 2001: SB63-66 insertion technique for the treatment of periprosthetic supracondylar femur frac-
7. Fulkerson E, Koval K, Preston C, et al. Fixation of periprosthetic femoral shaft tures above a total knee arthroplasty. JOT 20(3), 2006: 190-196
fractures associated with cemented femoral stems. JOT 20(2), 2006: 89-93 19. Richter M, Droste P, Goesling T, et al. Polyaxially-locked plate screws increase sta-
8. Fulkerson E. Egol K, Kubiak E, et al. Fixation of diaphyseal fractures with a seg- bility of fracture fixation in an experimental model of calcaneal fracture. JBJS(B),
mental defect: a biomechanical comparison of locked and conventional plating 88(9), 2006: 1257-1263
techniques. J Trauma 60, 2006: 830-835 20. Sanders R, Haidukewych G, Milne T, et al. Minimal versus maximal plate fixation
9. Gardner M, Griffith M, Demetrakopoulos D, et al. Hybrid locked plating of techniques of the ulna: the biomechanical effect of number of screws and plate
osteoporotic fractures of the humerus. JBJS(A), 88(9), 2006: 1962-1967 length. JOT 16(3), 2002: 166-171

10. Gardner M, Brophy R, Campbell D, et al. The mechanical behavior of locking 21. Sommer C, Gautier E, Muller M, et al. First clinical results of the locking com-
compression plated compared with dynamic compression plates in a cadaver pression plate. 34, 2003: SB43-54
radius model. JOT 19(9), 2005: 597-603 22. Stoffel K, Dieter U, Stachowiak G, et al. Biomechanical testing of the LCP- how
11. Gautier e, Sommer C. Guidelines for the clinical application of the LCP. Injury can stability in locked internal fixators be controlled? Injury 34, 2003: SB11-19
34, 2003: SB63-76 23. Wagner M. General principles for the clinical use of the LCP. Injury 34, 2003:
SB31-42

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
316 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 317

USE OF BONE SUBSTITUTES IN THE TREATMENT OF

FRACTURES & NONUNIONS
Jeffery M. Smith, MD

Introduction nificant differences in clinical results and complication

SYMPOSIA TRAUMA
• Autologous cancellous bone grafting gold standard rates. Straightforward fixation augmentation technique.
• Limitations: Limited quantity, donor site morbidity Still limited in North America.
• No standard treatment for nonunions or delayed unions
Calcium Sulfates
• Saleh et al, Medscape, “Socioeconomic Burden of Traumatic
• BMP delivery
Tibial Fractures: Nonunion or Delayed Union”
• Autograft expander
• Delayed fracture healing – significant potential socioeco-
• McKee et al, J Orthop Trauma, 2002
nomic burden
• Borelli et al, Clin Orthop Relat Res, 2003
• Nonunions – less frequent, but even greater negative impact
• Urban et al, Orthopedics, 2004
to direct (multiple procedures) and indirect costs (lost
• Watson, Orthopedics, 2004
work)
• Osteoconductive – scaffold for new bone formation Demineralized Bone Matrix
• Osteoinductive – induce pluripotential cells to change into • Osteoinduction
osteoblasts — Osteoinductive
— Similar to allograft except osteoinduction enhanced
Calcium Phosphates
— Sterilization diminishes osteoinduction
• Hydroxyapatite
• Comparable union rates with Autologous bone graft
— Slow resorption in vivo
— DBM with demineralized chips show more homogenous
• Tricalcium phosphate
fill than with mineralized chips and better fill and
— Rapidly resorption in vivo
remodeling than autologous graft
• New combinations
• Osteoinductivity varies across brands
— Zhang et al, J Mater Sci Mater Med, 2006
— Dependent upon processing of tissue and donor bone
— biocompatible and biodegradable polymer (chitosan)
— Strong association between BMP-2 and TGF-beta levels
and water-soluble porogen (mannitol) incorporated into
• Geesink et al, J Bone Joint Surg, 1999
CPC
• Hierholzer, J Bone Joint Surg, 2006
— Oda et al, J Orthop Sci, 2006
• Conclusion: Osteoinductivity depends upon fabrication
— XSB-671D hardens earlier,more resistant to body fluids
process and filler. Healing may depend upon osteoinduc-
• Used as void filler
tion plus angiogenesis. DMB may function well as an auto-
• Osteointegration
graft expander.
• No fibrous tissue interposition
• Some compressive strength Bone Morphogenic Proteins
• Augmentation of fracture fixation • TGF proteins with osteoinductive potential
• Minimal comparative studies • Induce cascade for chondro-osteogenesis
— General • Products
¬ Dickson et al, J Ortho Trauma, 2002 — rhBMP-2 (Infuse)
— Distal Radius Fractures — rhBMP-7 (OP-1)
¬ Sakano et al, J Hand Surg, 2001 • BMP-2
¬ Wolfe et al, J Hand Surg, 1999 — Gevender et al, J Bone Joint Surg (Am), 2002
¬ Sanchez-Sotelo et al, J Bone Joint Surg (Br), 2000 ¬ Recombinant human BMP-2 for treatment of open
¬ Zimmermann et al, Arch Orthop Trauma Surg, 2003 tibial fractures
¬ Cassidy et al, J Bone Joint Surg (Am), 2003 ¬ Prospective randomized 450 patients
— Intertrochanteric Hip Fractures • BMP-7
¬ Mattsson et al, J Bone Joint Surg (Br), 2005 — Friedlaender et al, J Bone Joint Surg (Am), 2001
— Femoral Neck Fractures ¬ Comparison to fresh autograft for tibial nonunions
¬ Mattsson and Larsson, Scand J Surg, 2003
Parathyroid Hormone
— Tibial Plateau Fractures
• Major regulator of bone and calcium metabolism
¬ Simpson and Keating, Injury, 2004
• Continuous administration leads to bone resorption
— Calcaneus Fractures
• Low pulsed doses lead to increases bone formation
¬ Schildhauer et al, J Ortho Trauma, 2000
— Enhanced mechanical strength and volume of callus in
— Conclusion: Evidence-based medicine shows modest dif-
animal studies
ferences in clinical results. There is increased cost.
— Induces anabolic effects on cancellous and cortical bone
Clinical use not fully defined.
• Andreassen et al, J Bone Metab Research, 1999
— Future: Newer products likely to have improved applica-
• Alkhiary et al, J Bone Joint Surgery, 2005
tion.
• Madore et al, J American Acad Orthopaedic Surgeons
• Hydroxyapetite Coated Pins and Screws
• Nakazawa et al, Bone, 2005
— Intertrochanteric Fractures
— Lower infection rate
— External fixation pins
— Conclusion: Evidence-based medicine shows some sig-
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
317
SYM 07:Layout 1 1/12/07 11:41 AM Page 318

Gene Therapy ¬ Herpes Virus

• Transfer of genetic material into individuals for therapeutic — Non-Viral
purposes by altering cellular function or structure at the ¬ Decreased technical demand
molecular level ¬ Less risk of immune response
• Strategies ¬ Safer
— In-vivo (direct) ¬ Not limited in amount of DNA accommodated
¬ Steps ¬ Less expensive
– Gene plus plasmid to homologous recombination ¬ Can include strategies such as naked DNA and a scaf-
– Insertion into viral or nonviral vector fold
SYMPOSIA TRAUMA

– Implantation into host • Cells

¬ Advantages — Bone marrow stem cells
¬ Disadvantages — Muscle-derived stem cells
— Ex-vivo (indirect) — Adipose-derived stem cells
¬ Steps — Fibroblasts
– Gene plus plasmid to homologous recombination — Peripheral-derived buffy-coat cells
– Infection and adenoviral replication • Scaffold
– Infect bone marrow or host cells — Host tissue (muscle flap, meniscus)
– Reimplant infected cells into host Advantages
¬ Advantages Disadvantages
¬ Disadvantages — Natural polymers (collagen, HA)
• Vectors Advantages
— Viral Disadvantages
¬ Highly efficient at infecting cells — Synthetic polymers (PLLA, PGA, PLGA)
¬ May transfer DNA to host without immune response Advantages
(some) Disadvantages
¬ Can be propagated in cell lines (if needed) — Injectable polymers (alginate)
¬ Adenoviruses Advantages
¬ Adeno-Associated Disadvantages
¬ Retroviral

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
318 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 319

FROM IRAQ - BACK TO IRAQ: MODERN

COMBAT ORTHOPAEDIC CARE (T)

SYMPOSIA TRAUMA
Moderator: Roman A. Hayda, MD, San Antonio, TX
(a - Smith and Nephew, Sofamor Danek, Synthes, Zimmer, b - Stryker Howmedica)
War injury will be discussed by a US tri-service panel of traumatologists focusing on results
and challenges providing insight on modern care of highly complex injuries.

I. Overview of Combat Injury

Roman Hayda, MD, San Antonio, TX (a - Smith and Nephew, Sofamor Danek,
Synthes, Zimmer, b - Stryker Howmedica)

II. Battlefield Care: Damage Control

Michael T. Mazurek, MD, San Diego, CA (n)

III. Casualty Evacuation: Transport of the Severely Injured

Elisha T Powell, MD, Elmendorf, AK (n)

IV. Reconstruction of Complex Injuries: Successes and Challenges

Romney Andersen, MD, Kensington, MD (b - Smith & Nephew)

V. Amputee Care: Current Concepts

H. Michael Frisch, MD, Silver Spring, MD (n)

VI. Future Directions in the Care of the War Injured

James R. Ficke, MD, Fort Sam Houston, TX (n)

VII. Perspectives of the Line Commander: Impact of Advanced Medical Care

David Rozelle, Alexandria, VA (n)

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
319
SYM 07:Layout 1 1/12/07 11:41 AM Page 320

FROM IRAQ-BACK TO IRAQ:

MODERN COMBAT ORTHOPAEDIC CARE
“He who would become a surgeon should join the Army and 3. Prevention of hemorrhage secondary to post-trau-
follow it.” Hippocrates matic coagulopathy
4. Expensive (effective)
1. Overview
v. Use of fresh whole blood
SYMPOSIA TRAUMA

1- Challenges Unique to War Trauma Surgery

1. Invaluable for clotting factors
i. Blast & high velocity missile wounds causing complex
2. Walking blood bank w/prescreened donors
wounds with frequent tissue loss and high degree of
3. Type/screen recipient
contamination
4. 450 cc drained into commercial blood bag
ii. Austere/dangerous environment
5. Donor’s blood sent for testing
iii.Limited resources
2- Useful Techniques in Frontline War Surgery
iv. Operational Tempo
i. Hypotensive resuscitation
2- Historical Perspective
1. Clot disruption occurs at BP of >80 mm Hg
i. Civil War: amputations
2. Benefits:
ii. WWI: value of early stabilization/transport
a. Preserves intravascular volume
iii.WWII: abx
b. Reduces dilutional coagulopathy
1. IM nail condemned!
c. Reduces hypothermia
iv. Vietnam: Medevac,
ii. Damage control surgery
1. ex fixes banned!
1. Advocated for unstable/extremis patients
v. Desert Storm: intro of modern orthopaedics—ex fix
2. Rapid temporary bony stabilization while limiting
3- Statistics
additional physiologic insult
i. KIA (Killed in Action)
3. Revascularization when necessary (Shunts)
ii. DOW (Died of Wounds)
iii.Management of War Wounds
iii.Survival rate (KIA/DOW)
1. War wounds are contaminated & should not be
iv. 55% extremity injury
closed primarily
v. 26% fractures
2. generous longitudinal incisions
vi. 82% of fractures open
3. Excise foreign material, devitalized tissue
4- Five Echelons of Care: orderly and rapid evacuation from
4. Irrigation
the war zone to definitive level of care is a critical com-
5. IV antibiotics
ponent in providing state of the art care to the wounded.
6. Ex fix or splint for transport/comfort
i. Echelon 1: battlefield care: buddy aid and medics
7. Fasciotomies
ii. Echelon 2 a: aid station/2b: Forward Surgical Team:
8. Stability
highly mobile austere surgical team providing life and
iv. Temporary Vascular Shunting
limb saving care.
1. Effectively controls hemorrhage
iii.Echelon 3: Combat support hospital: Field hospital
2. Rapidly restores blood flow to limb
with limited subspecialty and ICU care that prepares
3. Sets stage for definitive repair in cleaner environ-
for long distance transport
ment (Level III or higher sometimes by specialist)
iv. Echelon 4: Fixed facility at intermediate point of evac-
uation 3. Casualty Evacuation
v. Echelon 5: Definitive care facility 1- Transport of Stabilized but not necessarily stable patients
mandated
2. Battlefield Care: Damage Control
2- Echelon II to Echelon III via helicopter/ground transport
1- Front Line Hemorrhage Control Techniques
i. Enroute Care (ERC)
i. Tourniquets
ii. Hypothermia is an issue
1. Tested 7 different self applied tourniquets
3- Echelon III to IV and IV to V
2. Windlass or Pneumatic Compression essential
i. CCATT/SMART (burns)
ii. HemCon
1. provide ICU level care for long distance air trans-
1. Derived from natural polymer in shell fish
port
Chitosan
2. Absorbs water and creates an adhesive material that 4. Reconstruction of Complex Injuries: Successes and
sticks to the underlying tissue Challenges
3. Initially tested in Grade V Liver Lacerations 1- Treatment algorithm
iii.QuikClot i. Head to Toe Evaluation (On Admission)
1. Biologically inert mineral zeolite ii. Imaging Studies (On Admission)
2. FDA approved for external use iii.Wound Evaluation (First 24 Hours)
3. Absorbs water causing an exothermic reaction iv. Wound Debridement: 3-5 Iterations
4. Tested in swine model with a simulated groin v. Definitive Fixation
wound and division of femoral artery and vein. vi. Multidisciplinary Approach
(0% mortality) 1. Orthopaedic Surgery
5. Used by USMC 2. Plastic Surgery
iv. NovoSeven Factor VII 3. General Surgery
1. FDA: hemophiliacs 4. Vascular Surgery
2. Causes clot at site of damaged endothelium 5. Rehabilitation
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
320 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 321

2- Open Subtrochanteric Fractures iii.Associated Fractures

i. 44 Fractures 1. Distal Femur 64%
1. 56% IIIA 2. Proximal Tibia 59%
2. 22% IIIB iv. Treatment
3. 22% IIIC 1. Reconstruction 47%
ii. Infection 2. Fusion 29%
1. IIIA – 40% Sup 0% Deep 3. AKA 35%
2. IIIB/C – 75% Deep/Osteo v. Complications
iii.Definitive Fixation – 11.5 days 1. Decreased ROM

SYMPOSIA TRAUMA
1. Intramedulary Nailing 78% 2. Infection
2. Ex-Fix 22% 3. Function
3. Flap Coverage or Wound Closure 7- Burns
3- Open Tibia Fractures i. 5% of All Casualties Have Burns
i. 262 Open Fractures (90% of Tibia Fx) ii. Most Have Fractures
1. IIIA 42% iii.Extremely Difficult Management and Decision
2. IIIB 58% Making
3. IIIC 10% iv. Complications
ii. Mode of Fixation 1. infection
1. Nail 10% 2. wound healing
2. Ex-Fix 83% 3. contracture
3. ORIF 7% 8- Challenges of limb salvage
iii.Deep Infection i. Heteotopic Ossification
1. Nail 9% 1. 31% with Long Bone Fractures
2. Ex-Fix 0 % 2. Correlated with:
3. 11% Pin Tract Inf a. Higher ISS
4. BMP 3% b. Hip & Femur Fractures
iv. Union 3. Negative Correlation with:
1. Nail 91% a. Grade I Open Fracture
2. Ex-Fix 100% b. Tibia Fracture
v. Conversion to Amputation c. No Increased Association with
1. IIIA 0% d. VAC Use
2. IIIB 19% e. Head Injury
3. IIIC 82% f. Burns
4- Radial Segmental Defects ii. Infection
i. 10 Fractures with multiple Associated Injuries 1. 60% Deep Culture Positive at Presentation to
1. Autologus 80% Definitive Care Center
2. Allograft 10% 2. Klebsiella, Pseudomonas very Difficult to Eradicate
3. Free Vascularized 10% 3. Acinetobacter Ubiquitous in Theater – Some Multi
ii. 100% Healed Drug Resistant
iii.Morbidity – Function Related to Soft Tissue Injury 4. Long Term Consequences?
5- Open Elbow Injuries 5. Criteria for definitive fx care—Current standard:
i. 64 Open Elbow Injuries with severe soft tissue injury wounds Ready to Close As Graded By Attending
1. IIIA 42% Surgeon
2. IIIB 38% 6. Pilot study of wound exudate
3. IIIC 18% a. Wound Dehiscence Correlated with:
4. Bone Loss i. Exudate N-ProCT
a. Major Articular Loss 24% ii. Eotaxin
b. Metaphyseal Loss 30% iii.GM-CSF
c. Diaphyseal Loss 9% iv. IL-1b
ii. Fixation v. MIP-1
1. ORIF 90% vi. MIP-1a
2. Ex-Fix 7% vii. RANTES
3. Amputation 3%
5. Amputations: Current Concepts
iii.Function Related to Tissues Injured
1- Stats:
1. High Rates of HO
i. Civil War 12% (~50,000)
2. None Requesting Amputation
ii. WWI 1.7% (2,610)
6- Knee Extensor Mechanism Injuries
iii.WWII 1.2% (7,489)
i. 19 Open Traumatic Extensor Mechanism Injuries
iv. Korean War 1.4% (1,477)
1. Quad Tendon 35%
v. Vietnam 3.4% (5,283) 20% multiple
2. Patella 41%
vi. GWOT 2.3% (484) 16% multiple
3. Patella Ligament 65%
2- Additional Factors
4. Tibial Tubercle 24%
i. 39% have additional fractures (1-7 fxs Avg 2)
ii. Grade
ii. 45% have infections (1-11 sites Avg 1)
1. IIIA 41%
iii.12% have nerve injuries (1-5 nerves Avg 1)
2. IIIB 59%
iv. 41% have other significant soft tissue injuries (5-7
3. IIIC 0%
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
321
SYM 07:Layout 1 1/12/07 11:41 AM Page 322

sites Avg 2) 1. Blast IN ZOI (zone of injury) (147): 80%; 45%

3- Treatment principles Open Length Preserving 2. Blast above ZOI (40): 15%; 3%
Amputations 3. Non-Blast IN ZOI (20): 55%; 25%
i. In theater 4. Non-Blast above ZOI (6): 0%; 0%
1. excise all necrotic tissue iv. Lessons learned
2. preserve all viable tissue to include bone that can 1. Skin graft adherent to bone cannot be saved
be covered with atypical flaps 2. Neurovascular Structures may be encompassed
3. remove all foreign debris 3. Leaves large dead space, difficult to manage
4. preserve maximal options of definitive care 4. Local tissues do not rotate nicely into the void
SYMPOSIA TRAUMA

ii. Circular Amputations are Avoided 5. Higher risk of post operative infection
iii.Creative myodesis and closure when wound is ready 6. Expectations
iv. Fixation of fractures and other injuries 7. Longer healing time
v. Return to OR sooner than later to avoid higher level 8. Possible staged or follow-up surgery
resection 11- Myodesis Failure
4- Skin traction: standard during previous conflicts i. Suture Choice
i. Gel liners improvement over glued stockinet. ii. Fiber Wire
ii. Frequent painful dressing changes iii.Subclinical Infection
iii.Infection Low, Healing High iv. Activity Level ?
iv. Revision rate high 12- METALS Military Extremity Trauma Amputation and
v. Traction Works, but traction = bed time Limb Salvage Study
5- Vac and Vessel Loop Skin Traction i. Lower and Upper Extremity Injuries
i. Prevents Skin retraction ii. Outcome study of amputation vs salvage
ii. Decreases Edema
6. Combat Injured Extremity Care Future Directions
iii.Maintains drainage
1- Far Forward Casualty Care
iv. Contains Wound
i. Theater Trauma System
v. Allows Mobility
1. Centralized trauma care
6- Fracture Fixation in select cases preserves critical length
2. High volume setting
7- Rehabilitation is Vital: Outcome determined more by
3. Joint Theater Trauma Registry
aggressive and comprehensive rehab program than by
ii. Basic Principles of debridement and stabilization
surgery
should not change
i. Prosthetic management in year one is a process
iii.Evacuation
ii. Prosthetic rehab is NOT a specific component or device
1. Average time from injury to definitive facility- 5-7
iii.What is the Best Amputee Care Program
days
1. One where the amputee is not isolated
2. CCAT teams - 1-2 days
2. Useful for the surgical care and expertise
3. Negative pressure dressings
3. Absolutely vital for the rehab and prosthetic care
4. Pain pumps
iv. Phase 1: Protective Healing (early bed/mat activities)
2- Limb Salvage
v. Phase 2: Pre-Prosthetic (from final closure to prosthe-
i. Timing of conversion from external fixation
sis)
ii. Segmental bone loss
vi. Phase 3: Prosthetic Training (gait TNG, balance, pro-
iii.Soft tissue coverage
prioception, strength)
iv. Timing
vii. Phase 4: Return to Duty/Progressive Activities (func-
v. Techniques
tional drills, sports-specific, plyometrics, military skill
3- Amputee Care
TNG, gym program, running)
i. Geographic centers of excellence
8- Amputation does not mean discharge
ii. Prosthetic design
i. Return To Duty
iii.Rehab team
1. 44 (18%) 7 have redeployed
4- THE CENTER FOR THE INTREPID
9- Other misconceptions
i. Target- amputees & limb salvage pts
i. Revise Short BKA to Higher Level
ii. COLLABORATIVE POTENTIAL
1. no absolute Minimum Length
1. Education and Training
2. Preserve Joints if at all possible
2. Prosthetic residency and certifications
3. Short BKA better than a higher level
3. Physical Medicine and Rehabilitation
4. Excision of fibula may assist with closure and pros-
4. Occupational Therapy
thetic fitting
5. Physical Therapy
ii. Hip Disarticulations Won’t Walk
6. Research Development and Advanced Technologies
1. Prosthetic Advances C – Leg combined with
7. National and International
Vacuum Suspension
8. DoD/VA
iii.Ertl vs Burgess BKA ?
9. Research oversight board
1. No differences observed in prosthetic fitting or
10. Sustainment of CFI
rehabilitation
5- Research
2. Outcomes Study pending
i. Extremity War Injury Symposium
10- Challenges: Heterotopic Ossification
ii. Orthopaedic Trauma Research Program
i. Cuases: Pain, Skin Breakdown, Inability to fit or mod-
iii.Military Amputee Research Program
ify socket
iv. METALS
ii. Current Prevalence
v. Research Priorities Orthopaedic Research Priorities
iii.62% with some HO; 33% Moderate/Severe
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
322 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 323

EWI- January 2006 3. Improved outcomes of high energy contaminated

1. Data Collection Systems wounds
2. Timing of Treatment 4. Development of antiinfective acute wound care gel
3. Techniques of debridement 5. Cellular therapy to obtain rapid bone formation
4. Transport Issues 6. Controlled delivery of segmental defects with
5. Coverage Issues growth factors
6. Antibiotic Treatments 7. Adipose-derived stem cells for Tx of large bone
7. Management of segmental Bone Defects defects
8. Development of an animal model 8. Bone formation in infected segmental defects w/

SYMPOSIA TRAUMA
9. Amputee Issues BMP
10. Heterotopic Ossification 9. Modification of animal osteo model to simulate/
vi. Orthopaedic Trauma Research eval war extremity wounds
1. 2006- $7.5M funding 10. Expanded options with antibiotic bone cement
2. 14 approved proposals 11.Serum markers- predictors of war wound infections
3. 2007- Additional funding anticipated
4. Extremity War Injury Symposium 2- Jan 23-4, 2007 DISCLAIMER The views expressed in this presentation are those of the speakers and
vii. OTRP- Funded Proposals do not represent those of the Armed Services, the Department of Defense or the
1. Mechanisms of HO U.S.Government.
2. Prevention/ Rx of HO

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
323
SYM 07:Layout 1 1/12/07 11:41 AM Page 324

BATTLEFIELD STABILIZATION
Michael Mazurek, MD

I. Hemmorage Control Reduces hypothermia

1. Tourniquets: 5. NovaSeven (factor VII)
The Isreali Experience: • FDA approved for hemophiliacs
• 550 IDF Battlefield Casualties (4 yrs) • Causes clotting at site of damaged endothelium
SYMPOSIA TRAUMA

• 91 Tourniquets applied (78% Blast Injury) • Adjunct for prevention of hemorrhage secondary to
• None of the 125 fatalities related to limb exsanguina- post-traumatic coagulopathy (metabolic derange-
tions ments, hypothermia, and depletion or dysfunction of
• Only 7 neurogenic complications (Time 100- cellular and protein components)
180minConclusion: • Expensive (effective)
• Effective and safe means of prevention of fatal limb 6. Fresh Whole Blood
exsanguinations on the battlefield • Invaluable for clotting factors
Development of self applied tourniquets: • Walking blood bank w/prescreened donors
• 20 Healthy Volunteers (US Army Institute of Surgical • Type/screen recipient
Research) • 450 cc drained into commercial blood bag
• Tested 7 different self applied tourniquets • Donor’s blood sent for testing
• Elimination of distal Doppler flow
III. Extremity Damage Control
• Conclusion: 3 commercially available tourniquets
1. Damage Control Orthopaedics
occluded Doppler flow 100% in both upper and
Principles
lower extremity
• Advocated for unstable/extremis patients
• Combat Application Tourniquet, Special Operation
• Rapid temporary bony stabilization
Forces Tactical Tourniquet, Emergency & Military
• Revascularization when necessary (Shunts)
Tourniquet
• Limit additional physiologic insult
• Windlass or Pneumatic Compression essential
• Avoid immediate definitive surgery
2. Heme Con
1. Stop the Bleeding
• Hemostatic dressing
2. Remove the Contamination
• Derived from natural polymer in shell fish
3. Restore the Blood Flow
• Absorbs water and creates an adhesive material that
4. Stabilize Fractures
sticks to the underlying tissue
5. Don’t burn bridges for the next guy
• Initially tested in Grade V Liver Lacerations
2. Stabilization
• Used by the US Army
Benefits
3. Quikclot
• Maintain perfusion
• Biologically inert mineral zeolite
• Prevent secondary injury
• FDA approved for external use
• Blunt systemic response
• Absorbs water causing an exothermic reaction
• Pain control
• Tested in swine model with a simulated groin wound
• Options in Battlefield Setting; Splints, Traction,
and division of femoral artery and vein. (0% mortality)
External Fixation
• Used by USMC
3. Revascularization
II. Damage Control Surgery Temporary Vascular Shunting
1. Developed as strategy for multivisceral injuries in exsan- • Damage control for injured blood vessels
guinating patients • Placement of silicone tube to bypass injured segment
2. Rapid surgery, large incisions of vessel(s)
3. Stop bleeding & contamination • Effectively controls hemorrhage
3 PHASES • Rapidly restores blood flow to limb
1. Control hemorrhage, remove contamination • Sets stage for definitive graft
2. Re-warm, correct volume & coagulopathy 4. Antibiotics
3. Re-explore, definitive repair 5. Wound Containment
4. Hypotensive Resuscitation*
IV.Rapid Evacuation
• Clot disruption occurs at BP of 80/-
1. Emergent Evacuation
• Benefits:
2. Hypothermia Prevention
Preserves intravascular volume
3. Information Transfer
Reduces dilutional coagulopathy

REFERENCES: 3. Giannoudis PV. Pape HC. Damage control orthopaedics in unstable pelvic ring
1. Bickell WH, et al. Immediate versus delayed fluid resusitation for hypotensive injuries. Injury. 35(7):671-7, 2004 Jul.
patients with penetrating torso injuries. NEJM 331(17):1105-1109. Oct 1994. 4. Hildebrand F. et al. Damage Control: Extremities. Injury. 35: 678-689. 2004
2. Chambers LW. et al. Tactical Surgical Intervention with Temporary Shunting of 5. Holcomb JB. Use of Recombinant activated factor VII to treat the Acquired
Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Coagulapathy of Trauma. Journal of Trauma-Injury Infection & Critical Care.
Unit’s Experience. Journal of Trauma-Injury Infection & Critical Care. 61(4):1155- 58(6):1298-1303, 2005 Jun.
61 2006 Oct. 6. Kenet G, et al. Treatment of traumatic bleeding with recombinant factor VIIa.
Lancet 354:1870 1999.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
324 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 325

7. Lakstein D, et al. Tourniquets for Hemorrage Control on the Battlefield:A 4-Year 12. Pape HC, van Griensven M, Sott AH, et al. Impact of intramedullary instrumen-
Accumulted Experience. Journal of Trauma-Injury Infection & Critical Care tation versus damage control for femoral fractures on immunoinflammatory
54:S221-225. 2003 parameters: prospective randomized analysis by the EPOFF study group. J
8. Lynn M. Jeroukhimov I. Klein Y. Martinowitz U. Updates in the management of Trauma. 2003;55:7-13
severe coagulopathy in trauma patients. Intensive Care Medicine. 28 Suppl 13. Przkora R. Bosch U. Zelle B. Panzica M. Garapati R. Krettek C. Pape HC. Damage
2:S241-7, 2002 Oct. control orthopedics: a case report. Journal of Trauma-Injury Infection & Critical
9. Martinowitz U. Zaarur M. Yaron BL. Blumenfeld A. Martonovits G. Treating trau- Care. 53(4):765-9, 2002 Oct.
matic bleeding in a combat setting: possible role of recombinant activated factor 14. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an approach
VII. Military Medicine. 169(12 Suppl):16-8, 4, 2004 Dec. for improved survival in exsanguinating penetrating abdominal injuries. J
Trauma. 1993; 35: 375–382.

SYMPOSIA TRAUMA
10. Martinowitz U. Kenet G. Segal E. Luboshitz J. Lubetsky A. Ingerslev J. Lynn M.
Recombinant activated factor VII for adjunctive hemorrhage control in trauma. 15. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to
Journal of Trauma-Injury Infection & Critical Care. 51(3):431-8; discussion 438- intramedullary nailing for patients with multiple injuries and with femur frac-
9, 2001 Sep. tures: damage control orthopedics. J Trauma. 2000;48:613-623
11. Martinowitz U. Kenet G. Lubetski A. Luboshitz J. Segal E. Possible role of recom- 16. Walters TJ, et al. Effectiveness of Self Applied Tourniquets in Human Volounteers.
binant activated factor VII (rFVIIa) in the control of hemorrhage associated with Prehospital Emergency Care. 9(4):416-422 Oct/Dec 2005.
massive trauma. Canadian Journal of Anaesthesia. 49(10):S15-20, 2002 Dec.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
325
SYM 07:Layout 1 1/12/07 11:41 AM Page 326

FRACTURES ABOUT THE KNEE:

NEW TREATMENT METHODS AND
SYMPOSIA TRAUMA

STABILIZATION CHOICES
Moderator: James P. Stannard, MD, Birmingham, AL (a - Smith & Nephew)

This symposium will discuss the management, complications, and new stabilization
options for supracondylar femur and tibial plateau fractures, as well as fracture dislocations.

I. Introduction
James P. Stannard, MD, Birmingham, AL (a - Smith & Nephew)

II. Challenges and Problems with Fractures About the Knee

Lisa Cannnada, MD, Dallas, TX (e - Medtronic Sofamer Danek)

III. Supracondylar Femur Fractures

William M. Ricci, MD, Saint Louis, MO (a - AONA, a, e – Smith & Nephew)

IV. Tibial Plateau/Proximal Tibia Fractures

J. Tracy Watson, MD, Saint Louis, MO (n)

IV. Fracture Dislocation of the Knee

James P. Stannard, MD, Birmingham, AL (a - Smith & Nephew)

V. Question and Answer/Discussion Session

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
326 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 327

CHALLENGES AND PROBLEMS WITH FRACTURES

ABOUT THE KNEE
Lisa K. Cannada, MD

I. Review of Challenges posed by fractures about the knee with plate application laterally has been shown to have

SYMPOSIA TRAUMA
a. High energy injuries the biomechanical strength to obviate the need for double
Fractures about the knee represent a diverse group of plating.
injuries. There are those resulting from low energy in oste-
Pearl: With fixed angle plates, study the pre-operative CT
penic bone to high energy and possibly limb threatening
carefully to ensure stabilization of all major fragments.
injuries. The metaphyseal location and preponderance of
Consider augmentation outside of the plate, possibly sep-
cancellous bone can lead to significant comminution of
arate incisions and remember if lag screw fixation desired,
fractures in this region. As a result, these injuries can pose
do so before you lock!
challenges to the orthopedic surgeon, and meticulous
attention to preoperative planning with full consideration Pearl: Don’t forget the basic tenets of fracture fixation:
of all patient factors (condition of the soft tissue, con- bone grafting may be needed even with the biomechani-
comitant injuries, co morbidities, functional level prior to cally stronger locking plate constructs.
injury) is paramount.
II. Outcomes in the Literature Using Standard Treatments
Pearl: Computed tomography provides details regarding
a. Surpracondylar femur fractures
intraarticular involvement and can identify coronal plane
The standard treatment in the past had been condylar
deformities in the distal femur with reconstruction views
plating systems which required the placement of medial
and also provide details regarding a posteromedial frag-
fixation and the liberal use of autogenous bone graft to
ment in tibia plateau fracture (both of which are impor-
promote union and prevent varus collapse. Often these
tant in pre-operative planning).
techniques required large open exposures leading to unac-
b. Soft tissue problems ceptably high rates of infection. As a result, biological
Bridging external fixation may be advantageous as a tem- reduction techniques that emphasized limited lateral
porizing measure in open fractures, fractures with signifi- exposures and preservation of the soft tissue attachments
cant comminution or soft tissue compromise. Once the to the medial fragments were applied. Subsequent studies
soft tissues have been stabilized, the surgical approach and utilizing these techniques coupled with improved
tactic is dictated by the degree of articular comminution implants enabled equal results with regard to union and
and location of fracture fragments. overall function, less need for the use of autogenous graft,
and a substantial decrease in the rate of infections and
The incidence of compartment syndrome increases with
other soft tissue complications. The debate in recent years
severity of the tibial plateau fracture and patients should
has now shifted to the optimal application of newer
be closely monitored. In addition, the occurrence of liga-
implants including locked plate technology and retro-
mentous injury and meniscal injury with tibial plateau
grade femoral nails with very distal locking holes specifi-
fractures should not be overlooked. Many of these soft tis-
cally designed for supracondylar fractures.
sue injuries to structures of the knee are difficult to detect
by physical exam and obtaining MRI scans when the sus- b. Tibial plateau fractures
picion is high may change the treatment plan. Much like supracondylar femur fractures, the treatment
options in the past included double plating of bicondylar
Pearl: There should be careful evaluation of neurovascular
fractures. Large open procedures were required and often
status due to the proximity of vascular structures to the
results were less than optimal and there were frequent
fracture. If the fracture is associated with a dislocation,
complications. Now for all tibial plateau fractures, treat-
angiography may be considered as the risk of vascular
ment options are plentiful. Many aspects have been stud-
injury is significantly greater with associated dislocation.
ies, including the size of screws and plates. Small fragment
Pearl: If there is more than 6 mm widening or 5 mm fixation is acceptable. Staged reconstruction techniques for
depression with a tibial plateau fracture, your suspicion high energy fractures has resulted in changing thoughts
for injury to the knee structures should be increased. regarding treatment with better outcomes. Careful pre-
operative evaluation of the fracture type and forces leading
c. Biomechanics
to the fracture can assist in optimizing your result.
It is important to consider the forces which cause fractures
and soft tissue injuries about the knee. The fixation devices The concern for post-traumatic arthritis is always on one’s
chosen must be designed for and appropriately applied to mind when treating these intraarticular fractures. Recent
resist the deforming forces. The fracture pattern is depend- long term functional results indicate satisfactory knee
ent upon the position of the knee at the time of injury and function can be achieved even with high energy injuries.
the force vector. Ligamentous and meniscal injuries are Short term results of bicondylar fractures treated with
more common with rotational and shearing forces. Axial locking plates through a minimimally invasive approach
loads and bending contribute to the fracture pattern. are promising.
In the past, double plating of bicondylar fractures about III. Complications associated with Fractures about the Knee
the knee was standard through big incisions and bone a. Supracondylar femur fractures
grafting. With the use of locking plates, single incisions

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
327
SYM 07:Layout 1 1/12/07 11:41 AM Page 328

Nonunion: The rates of both nonunion and infection Wound Complications: The high energy nature of
have improved with the use of more biologically friendly bicondylar tibial plateau fractures is often accompanied
techniques. Nonunions should be treated with bone graft- by a compromised soft tissue envelope. The complications
ing and/or implant revision. include wound breakdown, exposed hardware and infec-
tion can be minimized by staged procedures using a tem-
Infection: As mentioned there is a decreased rate of infec-
porary, bridging external fixator initially then proceeding
tion with tissue friendly techniques. Infection should be
with formal ORIF when soft tissue permits.
managed with thorough debridement, cultures and
appropriate antibiotics and consideration of removal of Pearl: When using a bridging external fixator, draw any
SYMPOSIA TRAUMA

hardware if fracture permits planned surgical incisions so as to place the external fixa-
tor pins outside of the zone of surgery.
Implant failure: A recent case series demonstrated six fail-
ures of the locking condylar plate in patients with either
IV.Brief Introduction to New Technologies to address prob-
significantly poor bone stock or in patients who had sig-
lems
nificant bone loss associated with their open fractures.
Fixation Methods
Cyclical loading of even these stronger implants in the face
The trend in recent years regarding periarticular fractures
of nonunion will inevitably lead to failure, and the selec-
had changed from large, extensile approaches, subpe-
tive use of autogenous bone graft, methylmethacrylate
riosteal dissection, circumferential clamps, and absolute
cement and/or the cautious advancement of weight bear-
stability to the concept of biological reduction techniques
ing status based on clinical and radiographic signs of
that emphasized limited lateral exposures and preserva-
union are critical in avoiding failure.
tion of the soft tissue attachments. The locking plate has
b. Tibial plateau fractures become quite popular.The optimal application of these
Loss of Fixation/Reduction: The collapse into a malunion plates will be addressed in this symposium along with the
or the loss of articular reduction may have adverse impli- use of external fixators.
cations for the patient. There always has been question
Void Fillers
regarding how much joint step off is acceptable, but post
With depressed tibial plateau fractures, once there was ele-
operative loss of reduction is problematic. The use of pre-
vation of the articular fragment, a void existed. Previously,
contoured plates with rafting screws to support the sub-
cancellous autograft was used. Now, with emerging tech-
chondral surface has promising results. It is important to
nology, calcium phosphate cement has been shown to be
understand the biomechanics of the fracture and fixation
superior in preventing displacement compared to auto-
technique utilized to minimize this complication.
graft. The use of bone graft substitutes which provide sim-
Pearl: Failure of fixation may be due in part to bone qual- ilar or improved results compared to iliac crest bone graft-
ity. Locking plates have been demonstrated to have better ing without the morbidity of bone graft harvesting will be
purchase in poor quality bone and should be considered a major advance in our treatment armentarium.
for fixation in elderly patients.

REFERENCES 11. Markmiller M, Konrad G, Sudkamp N: Femur-LISS and distal femoral nail for
1. Ali AM, El-Shaife M, Willett KM. Failure of fixation of tibial plateau fractures. J fixation of distal femoral fractures. Clin Orthop 2004;426:252-257.
Orthop Trauma 2002; 16:323-329. 12. Marsh JL, Bulkwalter J, Gelberman R, et al. Articular fractures. Does an anatom-
2. Bai B, Kummer FJ, Sala DA, Koval KJ, WOlinsky PR. Effect of articular step-off ic reduction really change the result? J Bone Joint Surg Am 2002; 84-A:1259-
and meniscectomy on joint alignment and contact pressures for fractures of the 1271.
lateral tibial plateau. J Orthop Trauma 2001; 15:101-106. 13. Nork SE, Segina DN, Aflatoon K et al. The association between supracondylar-
3. Bolhofner BR, Carmen B, Clifford P: The results of open reduction and internal intercondylar distal femur fractures and coronal plane fractures. J Bone Joint Surg
fixation of distal femur fractures using a biologic (indirect) reduction technique. Am. 2005;87:564-569.
J Orthop Trauma 1996;10:372-377. 14. Vallier HA, Hennessey TA, Sontich JK, Patterson BM: Failure of LCP condylar
4. Cole PA, Ziowodsku M, Kregor PJ. Less invasive stabilization systems (LISS) for plate fixation in the distal part of the femur. A report of six cases. J Bone Joint
fractures of the proximal tibia: Indications, surgical technique, and preliminary Surg Am 2006;88:846-853.
results of the UMC Clinical Trial. Injury 2003; 34 (suppl 1):A16-A19. 15. Weight M, Collinge C: Early results of the less invasive stabilization system for
5. Cooper HJ, Kummer FJ, Egol KA, Koval KJ. The effect of screw type on fixation mechanically unstable fractures of the distal femur (AO/OTA types A2, A3, C2,
of depressed fragments in tibial plateau fractures. Bull Hosp Jt Dis 2001-2002; and C3). J Orthop Trauma 2004;18:503-508.
60:72-75. 16. Weigel DP, Marsh JL. High-energy fractures of the tibial plateau: Knee function
6. Egol KA, Su E, Tejwani NC, Sims SH, Kummer FJ, Koval KJ. Treatment of com- after longer follow-up. J Bone Joint Surg Am. 2002; 84-A:1541-1551.
plex tibial plateau fractures using the less invasive stabilization system plate: 17. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK:
Clinical experience and a laboratory comparison with double plating. J Trauma Intra-articular fractures of the distal femur: A long term follow-up study of surgi-
2004; 57:340-346. cally treated patients. J Orthop Trauma 2004;18:213-219.
7. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C. 18. Stevens DG, Beharry R, McKee MD, Waddell JP, Schmeitsch EH. The long-term
Single lateral locked screw plating of bicyondylar tibial plateau fractures. Clin functional outcome of operatively treated tibial plateau fractures. J Orthop
Orthop Relat Res 2005;439:207-214. Trauma 2001; 15:312-320.
8. Handolin L, Pajarinen J, Lindahl J, Hirvensalo E: Retrograde intramedullary nail- 19. Trenholm A, Landry S, McLaughlin K, Deluzio KJ, Leighton J, Trask K, Leighton
ing in distal femoral fractures: Results in a series of 46 consecutive operations. RK. Comparative fixation of tibial plateau fractures using alpha-BSM, a calcium
Injury 2004;35:517-522. phosphate cement, versus cancellous bone graft. J Orthop Trauma
9. Karunakar MA, Egol KA, Peindl R, Harrow ME, Bosse MJ, Kellam JL. Split 2005;19(10):698-702.
depression tibial plateau fractures. A biomechanical study. J Orthop Trauma 20. Watson JT, Ripple S, Hoshaw SJ, Fhyrie D. Hybrid external fixation for tibial
2002; 16:172-177. plateau fractures: Clinical and biomechanical correlation. Orthop Clin North
10. Kregor PJ, Stannard JA, Zlowodzki M, Cole PA: Treatment of distal femur frac- Am 2002; 33:199-209.
tures using the less invasive stabilization system. J Orthop Trauma 2004;18:509- 21. Westmoreland GL, McLaurin TM, Hutton WC. Screw pullout strength: A biome-
520. chanical comparison of large-fragment and small-fragment fixation in the tibial
plateau. J Orthop Trauma 2002; 16:178-181.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
328 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 329

22. Yacoubian SC, Nevins RT, Sallis JG, Potter HG, Lorich DG. Impact of MRI on 24. Zlowodzki M, Williamson S, Cole PA, Zardiackas LD, Kregor PJ: Biomechanical
treatment plan and fracture classification of tibial plateau fractures. J Orthop evaluation of the less invasive stabilization system, angled blade plate, and retro-
Trauma 2002; 16:632-637. grade intramedullary nail for the internal fixation of distal femur fractures. J
23. Yetkinler DN, McClellan RT, Reindel ES, Carter D, Poser RD. Biomechanical Orthop Trauma 2004;18:494-502.
comparison of conventional open reduction and internal fixation versus calcium
phosphate cement fixation of a central depressed tibial plateau fracture. J
Orthop Trauma 2001; 15:197-206.

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
329
SYM 07:Layout 1 1/12/07 11:41 AM Page 330

DISTAL FEMUR FRACTURES

Willim M. Ricci, MD
SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
330 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 331

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
331
SYM 07:Layout 1 1/12/07 11:41 AM Page 332

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
332 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 333

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
333
SYM 07:Layout 1 1/12/07 11:41 AM Page 334

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
334 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 335

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
335
SYM 07:Layout 1 1/12/07 11:41 AM Page 336

FRACTURES ABOUT THE KNEE: NEW TREATMENT METHODS

AND STABILIZATION CHOICES
J. Tracy Watson, MD

TIBIAL PLATEAU PROXIMAL TIBIA FRACTURES

SYMPOSIA TRAUMA

1. Soft tissue considerations as well as specific fracture patterns

will help to determine the indications for VARIOUS fixation
techniques in the treatment of tibial plateau fractures.
In general, fixation can be divided into two basic categories:
• Temporary spanning fixators followed by defintive ORIF
• Adjunctive or definitive treatment internal fixation or exter-
nal fixation
LOW ENERGY FRACTURE PATTERNS
More likely to utilize only temporary spanning fixation ( in
cases of significant soft tissue compromise ) prior to definitive 5. Composite fixation
ORIF. Because of the straightforward fracture 1. Limited ORIF with medial fixator for medial
patterns....External fixation is rarely definitive Treatment. condyle
1. Type I - split condyle. Treatment alternatives 2. Limited CT directed exposure for articular reduc-
1. Ligamentotaxis with distractor tion and LIMITED ORIF with full ring fixator vs
2. Arthroscopy large pin mono-lateral fixator
3. Percutaneous reduction forceps 1) Beware of large half-pin fixation in the proximal
4. Cannulated screw fixation Metaphyseal areas…EARLY PIN LOOSENING,
5. Percutaneous SMALL WIRE or HYBRID fixator tech- Knee sepsis
nique 3. Hybrid Locked plating techniques
6. Atypical lateral plateau fractures may require tubercle 1) Allows the benefits of the precontoured plates to
plate and Ex-Fix achieve correct reduction…Locking screw bene-
2. Type II - split depression fits to maintain reduction in bicondylar fashion.
1. Book open split 6. Type VI - bicondylar extension
2. Reduce joint surface • Skin and soft tissues
3. Bone graft • Traction - cast brace
4. ORIF • Combined internal and mono-lateral large pin
a. MAY opt for hybrid technique to maintain reduc- external fixation
tion of condyle and articular surface with small • Ilizarov / Hybrid techniques>>>>>span dia-meta-
wire fixation (RARE INDICATIONS) physeal comminution
b. Plate design ..RAFT plate fixation • Locking plate…eliminate need for medial plate???
3. Type III - central depression NO ROLE FOR EXTERNAL OUTCOMES Long term results based on ability to
FIXATION maintain mechanical axis …not articular surface per-
1. Arthroscopy fection….
2. Cortical window
2. Decision Making in the Treatment of Bicondylar Tibial
3. Bone graft
Plateau Fractures
4. Screw fixation
1. Previously with low energy plateau fractures, the main
4. Type IV - medial plateau
goal is to restore joint congruency at all costs. With the
1. Rule out neurovascular injury
higher energy plateau fractures, this is still the main goal
2. Rule out ligamentous injury
but not at the expense of a wound complication.
3. ORIF buttress plate
RATHER…long term results are dependent upon the
4. SPANNING FIXATION ONLY ..IN THE FACE OF
maintenance of the mechanical axis…NOT the preserva-
COMPROMISED SOFT TISSUES.
tion of the joint surface primarily…
5. Type V - bicondylar plateau
1. Soft tissue assessment
2. Traction - cast brace
3. External fixation
4. ORIF
1. Locking plate applications help to prevent varus
collapse of medial condyle and may alleviate need
for medial /post medial plate.
2. LISS plate stabilization vs bicortical locking plating
system

Bicondylar fracture Rx’ed with lateral locking plate…will

these plates prevent varus collapse of the medial condyle

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
336 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 337

suspended on this cantilever. Construct??? able, which are generally ceramic-based materials.
Complete evaluation of the postero-medial apex fracture
line is indicated when evaluating a bicondylar fracture
pattern..the application of a second postero-medial or
direct medial plate should be applied at this apex…in
order to stabilze this medial condyle.…casual application
of a second plate without consideration of the location
of this apex will result in axial displacement of this
region and result in varus collapse…

SYMPOSIA TRAUMA
These materials have variable rates of incorporation and
Type II fracture CONCEPTS…RAFT PLATE FIXATION resorbtion. They are delivered in a number of application
Multiple 3.5 mm screws placed across metaphyseal methodologies…i.e pellets, Injectable self setting
region to be supported by the medial cortex and the lat- “cements” etc.
eral plate. These support points act as “rafters” to bear
the articular load placed on these transverse screws which EXTRA ARTICULAR PROXIMAL TIBIA FRACTURES
help to maintain and protect the articular surface from OPTIONS FOR TREATMENT
redisplacing. 1. IM nails
Location of fracture for their use….How far below the tibial
tubercle?
Specifics technical tips.
Blocking screws
Semi-extended position
Supra-patellar entry portal
Proximal anti-glide plate at anterior apex to prevent
extension of prox fragment
Results and complications…

Role of bone graft substitutes…or metaphyseal defects…

Multiple prospective studies have demonstrated the effi-
cacy of these materials when used to augment metaphy-
seal subchondral defects. The primary indication for their
use is during the stabilization of tibial plateau and pilon
fractures. These materials have been found to be an
excellent replacement for autogenous bone graft when
used to maintain the elevated articular defect following
plateau fracture fixation. These studies demonstrated the
ability to maintain the elevation of subchondral defects
better than autogenous bone grafts, as well as avoid the
complication of late
It has been shown experimentally that a simple meta-
physeal cancellous void will heal completely given a
sound biologic environment without the addition of any
further grafting material. The danger here is that the sub-
chondral surface will collapse if this defect does not
reconstitute fast enough to provide structural support.
Therefore, for the treatment of primary metaphyseal
defects, any osteoconductive substrate will be sufficient.
Synthetic substitutes without a biological component
have the advantage of laboratory synthesis with excellent blocking screws /schantz pins to avoid
batch to batch consistency. However, these alloplastic malalignment
substitutes rely on the body’s ability to regenerate bone.
They can be formulated to have specific handling charac-
teristics, in vivo residence times, adaptable delivery sys-
tems and no risk of disease transmission. A large variety
of synthetic alloplastic bone graft substitutes are avail-

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
337
SYM 07:Layout 1 1/12/07 11:41 AM Page 338

2. MIPO plating techniques for proximal extra-articular frac-

tures
SYMPOSIA TRAUMA

Intra-op traction films reveal reduction of metaphyseal

components…but also demonstrate the failure of ligamen-
totaxis to reduce a depressed articular surface. This is con-
Specific technical tips
firmed via traction CT scan. The Surgical tactic should be
1. Pt positioning,
directed to this depressed segment.
2. Application of distractor/ex fix for alignment and reduction
3. Hybrid screw application…..order of locking screw vs
non locking screw Placement
Results and complications
3. TIPS, TECHNIQUES and RESULTS OF RING FIXATOR
PLACEMENT

A limited lateral incision was utilized for Open reduction.

Percutaneous stabilization with a small wire ring fixator was
then carried out.

Initial injury films demonstrating Immediate traction film that reveals

A probable bicondylar fracture pattern. Near anatomic metaphyseal reduction.
Following ligamentotaxis reduction…Traction CT scan
should reveal adequacy of articular reduction.
Reduced —> Percutaneous stabilization
NOT Reduced —> Open reduction and stabilization

In the face of extensively comminuted metaphyseal condy-

lar fragments, anti-glide plates are necessary to prevent late
displacement. If a separate tubercle fragment is present, an
anterior hook plate or internal fixation is necessary as
anatomical constraints preclude the use of front to back
transfixation wires in this location

Fixation utlizing percutaneous cannulated screws and neu-

tralization with a small wire external fixator.

REFERENCES 7. Weiner LS. et.al. the Use of Combination Internal Fixation and Hybrid External
1. Schatzker J, et.al. The Tibial Plateau Fracture: the Toronto Experience 1968-75 Fixation in Severe Proximal tibia Fractures. J Ortho. Traums 1995;9:244-250.
Clin Ortho 1979; 138:94-104. 8. Watson JT. et.al. High-Energy Fractures of the Tibial Plateau Othop Clin North
2. Honkonen SE, et.al. Indications for Surgical treatment of Tibial Plateau Condyle Am 1994;25:723-752.
Fx. Clin Ortho 1994;302:199-205. 9. Watson JT et.al. The Treatment of complex lateral Plateau Fractures Using Ilizarov
3. Marsh JL, et. al. External Fixation and Limited Internal Fixation for Complex Techniques. Clin Ortho 1998;353:97-106.
Fractures of the Tibial Plateau. JBJS1995; 77A 10. Watson JT et.al Hybrid External Fixation for Tibial Plateau Fractures: Clinical and
4. Bernfeld B. et.al. Arthroscopic Assistance for Unselected tibial Plateau Fractures. Biomechanical Correlation. Othop Clin North Am. 2002;33:199-210.
Arthroscopy 1996;12:598-602. 11. Lansinger, O et.al.: Tibial Condylar Fractures: A Twenty-Year Follow-Up. J. Bone
5. Koval KJ et.al. Indirect Reduction and Percutaneous Screw Fixation of Displaced Joint Surg., 68A:13, 1986.
Tibial Plateau Fractures. J Orthop Trauma 1992; 10:304-308. 12. Kettelkamp, D.B et.al.: Degenerative Arthritis of the Knee Secondary to Fracture
6. DeBoeck H. et.al. Posteromedial Tibial Plateau Fractures: Operative Treament by Malunion. Clin. Orthop., 234:159, 1988.
Posterior Approach. Clin Ortho 1995; 320:125-128

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
338 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 339

13. Benirschke, S.K., et.al.: Immediate Internal Fixation of Open Complex Tibial 17. Watson JT. The Use of an Injectable Bone Graft Substitute in Tibial Metaphyseal
Plateau Fractures: Treatment by a Standard Protocol. J. Orthop. Trauma, 6:78, Fractures. Orthopedics 27(1): 103-105, 2004.
1992. 18. Ricci WM, Rudzki JR, Borrelli J Jr. Treatment of Complex Proximal Tibia Fractures
14. Rasmussen, P.S.: Tibial Condylar Fractures: Impairment of Knee Joint Stability as with the Less Invasive Skeletal Stabilization System. J Orthop Trauma. 2004
an Indicator for Surgical Treatment. J. Bone Joint Surg., 55A:1331, 1973. Sep;18(8):521-7.
15. Müller, M.E., Nazarian, S., Koch, P., et al.: The Comprehensive Classification of 19. Stannard JP, Wilson TC, Volgas DA, Alonso JE. Fracture stabilization of proximal
Fractures and Long Bones. New York, Springer, 1990. tibial fractures with the proximal tibial LISS: early experience in Birmingham,
16. Tay, B.K.B., V.V. Patel and D.S. Bradford, “Calcium Sulfate- and Calcium Alabama (USA). Injury. 2003 Aug;34 Suppl 1:A36-42.
Phosphate-based Bone Substitutes.” Orthopedic Clinics of North America, 4, 20. Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, Sangeorzan BJ.

SYMPOSIA TRAUMA
Oct. 1999: 615-623. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma.
2006 Sep;20(8):523-8.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
339
SYM 07:Layout 1 1/12/07 11:41 AM Page 340

FRACTURE DISLOCATION OF THE KNEE

James P. Stannard, MD

1. Incidence of Ligament Injuries Associated with Fractures 5. Place 3 tibial pins: 3, 4, and 5 hole rancho cube to
About the Knee get out of the zone of injury
a. Literature Review iii.Outcomes
i. Five published series using MRI to assess soft tissue 1. 7% ligament failure rate when ORIF is combined
SYMPOSIA TRAUMA

following tibial plateau fractures with placement of Compass Knee Hinge (CKH)
1. 197 total fractures and aggessive rehabilitation. 29% ligament failure
2. 54 (27%) Medial meniscus tears and 74 (38%) lat- rate without CKH.
eral meniscus tears d. Reconstruction options for the knee
3. 63 (32%) ACL tears, 45 (23%) PCL tears, 30 (15%) i. PCL – prefer inlay technique. Anatomic reconstruc-
PMC tears, and 54 (27%) PLC tears tion also features double bundle technique using
ii. Stannard series – 103 consecutive tibial plateau frac- achilles tendon allograft
tures evaluated with MRI. 45 (44%) ACL’s, 41 (40%) ii. ACL – prefer double bundle allograft reconstruction
PCL’s, 16 (16%) PMC’s, and 46 (45%) PLC’s torn. with achilles tendon allograft. Other options include
b. Timing of treatment BTB or hamstring allograft reconstructions
i. Fracture fixation and repair of any avulsed ligaments: iii.PMC – reconstruction should include deep MCL and
as soon as soft tissue and patient condition will allow. posterior oblique ligament.
Usually within 1 week. Spanning ex fix only if knee e. Outcomes
will not remain located. Otherwise, knee immobilizer i. Very few articles published regarding fracture disloca-
to allow soft tissue to recover prior to reconstructions. tions
ii. Knee reconstruction: ideally 3 – 4 weeks following ii. Unrecognized and therefore untreated ligament
injury injuries frequently have poor outcomes even if the
1. Delay PLC reconstruction until tibial plateau has fracture is well aligned and united.
healed enough to support trans-tibial tunnel. iii.40% poor outcome if knee injury is left untreated ver-
iii.Rehabilitation: early range of motion using CPM fol- sus 16% if it is treated.
lowing ligament reconstruction. iv. Aggressive treatment and rehabilitation (see CKH
c. Hinged External Fixator results above) probably yields the best results.
i. The ultimate knee brace f. Complications
1. Allows sagittal plane motion i. Limited data from studies that are limited to fracture
2. Does not allow varus/valgus or rotation dislocations
3. Protects both reconstructions and ORIF of tibial ii. Arthrofibrosis – seen in 38% of knee dislocations
plateau iii.PAIN – some pain in almost everyone. Severe in
ii. Technique tips and tricks some patients
1. Identify isometric spot using radiographic tech- iv. Ligament laxity – seen in 37% of knee dislocations.
nique See data above for fracture dislocations with hinged
2. Place two femoral pins – one posterolateral (3 hole external fixator
rancho cube) and one posteromedial (1 hole ran- v. Infection and soft tissue breakdown – High risk due
cho cube) to high energy injury and limited soft tissue coverage
3. Remove hinge and finish reconstruction around proximal tibia.
4. Replace hinge on femoral pins after closing all inci-
sions

REFERENCES 5. Brophy DP, O’Malley M, Lui D, Dennison B, Eustace S. MR imaging of tibial

1. Stannard, J and Martin, S. Chapter 29 – Tibial Plateau Fractures. Stannard JP, plateau fractures. Clin Radiol 1996; 51: 873 – 878.
Schmidt AH, Kregor PJ. Surgical Treatment of Orthopaedic Trauma. New York, 6. Holt MD, Williams LA, Dent CM. MRI in the management of tibial plateau frac-
NY: Thieme Medical Publishers; 2007. Pages 713 – 741. tures. Injury 1995; 26: 595 – 599.
2. Stannard, J and Schenck R. Chapter 28 – Knee Dislocations and Ligamentous 7. Kode L, Lieberman JM, Motta AO, Wilber JH, Vasen A. Yagan R. Evaluation of
Injuries. Stannard JP, Schmidt AH, Kregor PJ. Surgical Treatment of Orthopaedic tibial plateau fractures: efficacy of MR imaging compared with CT. Am J
Trauma. New York, NY: Thieme Medical Publishers; 2007. Pages 687 – 712. Roentgenol 1994; 163: 141 – 147.
3. Delamarter R and Holt M. The cast brace and tibial plateau fractures. Clin 8. Shepherd L, Abdollahi K, Lee J, Vangsness CT Jr. The prevalence of soft tissue
Orthop Relat Res 1989, 242: 26 – 31. injuries in nonoperative tibial plateau fractures as determined by magentic reso-
4. Barrow BA, Fajman WA, Parker LM, Albert MJ, Drvaroc DM, Hudson TM. Tibial nance imaging. J Orthop Trauma; 2002; 16: 628 – 631.
plateau fractures: evaluation with MR imaging. Radiographics 1994; 14: 553 –
559.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
340 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 341

MANAGING HIP FRACTURES

IN THE OSTEOPOROTIC PATIENT:

SYMPOSIA TRAUMA
WHAT IS THE EVIDENCE? (AA)
Moderator: Mohit Bhandari, MD, Hamilton, ON, Canada (n)

This symposium identifies current areas of controversy and evidence to guide health care
professionals in the management of hip fractures in osteoporotic patients.

I. Optimal Fixation For Femoral Neck Fractures

Emil H. Schemitsch, MD, Toronto, ON Canada (a, e – Stryker, a - Smith & Nephew)

II. Internal Fixation Versus Arthroplasty In Femoral Neck Fractures

Roy W. Sanders, MD, Tampa, FL (c, e – Smith and Nephew, Johnson and Johnson,
e -Stryker)

III. Optimal Arthroplasty: What Is The Evidence?

Mohit Bhandari, MD, Hamilton, ON, Canada (n)

IV. Optimal Fixation For Trochanteric Fractures

Michael R. Baumgartner, MD, New Haven, CT (b - AO Foundation,
e - Smith & Nephew)

V. Use Of Bone Substitutes: What Is The Evidence?

Antonio Moroni, MD, Bologna, Italy (n)

VI. Discussion, Question and Answer

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
341
SYM 07:Layout 1 1/12/07 11:41 AM Page 342

OPTIMAL ARTHROPLASTY: WHAT IS THE EVIDENCE?

Emil H. Schemitsch, MD

Displaced femoral neck fractures: POOLED TREATMENT EFFECTS FROM RANDOMIZED TRIALS:
The choice of internal fixation or hemi-arthroplasty (HA) or DIRECT COMPARISONS BETWEEN THA AND HA
total hip arthroplasty (THA) depends on patient characteristics N Baseline Rate: HA Relative 95% CI
and surgeon preference. (weighted) Risk*
SYMPOSIA TRAUMA

Primary Outcome:
Complications of arthroplasty:
Reoperation 180 13%(8.7%-18.5%) 0.86 0.47-1.59 P=0.63
• re-operations for dislocations Other Complications:
• wound infections Mortality 180 21.8%(16.4%-28.2%) 0.71 0.46-1.11 P=0.13
• peri-prosthetic fractures Dislocation 180 7.4%(4.4%-12.2%) 1.54 0.83-2.86 P=0.17
• intractable pain Wound Infection 180 5.4%(2.9%-9.8%) 0.69 0.26-1.85 P=0.46
• implant loosening Deep Venous 180 6%( 3.3%-10.4%) 2.95 0.40-21.74 P=0.29
Thrombosis
Advantages of hemi-arthroplasty: Pain and Function:
• reduced dislocation rates Hip pain 180 42.1%(35.9%-49.2%) 0.76 0.59-0.98 P=0.03
• lower rates of deep venous thrombosis Functional limitations 180 53.5%(46.4%-60.4%) 0.90 0.76-1.06 p=0.13
• shorter operating times
• less blood loss *Total hip arthroplasty versus hemi-arthroplasty. THA=total hip arthroplasty;
HA=hemi-arthroplasty
• technically less demanding procedure
• lower costs REVISION AND COMPLICATIONS FROM META-ANALYSES
(INDIRECT COMPARISONS)
Similar outcomes in terms of blood loss, length of hospital
stay, dislocation rates, post-operative pain, and recovery of Lu-Yao (1994) Bhandari (2001)
ambulatory status and activities of daily living or post-opera- THA HA THA HA
tive functional outcome scores between bipolar and unipolar (N=746) (4530) (N=105) (N=557)
Point Estimates Point Estimates
prostheses
(95% CI)** (95% CI)
Advantages of Total Hip Arthroplasty: Revision 5% 12.5% 7.5% 7.5%
• improved patient function (3.7, 6.8) (11.6, 13.5) (3.8, 14.2) (5.6, 10.0)
• improved quality of life Mortality 23% 27% 10% 37%
(20.1, 26.2) (25.7, 28.3) (5.6, 17.2) (33.1, 41.1)
Total hip replacement is the best pain relief procedure, Dislocation 10.7% 2.9% 7.0% 3.5%
although the rate of dislocation is high, a few of these are (8.7, 13.1) (2.4, 3.4) (3.5, 13.5) (2.3, 5.4)
recurrent, and the rate of loosening is high. A state of the art Wound Infection 1.0% 2.8% 2.0% 8.0%
stem design is important. The decision on cemented or unce- (0.5, 2.0) (2.4, 3.3) (0.6, 6.8) (6.0, 10.6)
Deep Venous NA 4.0% NR 2.5%
mented fixation should be based on the patient’s bone quality
Thrombosis (3.5, 4.6) (1.5, 4.2)
and function. Antero-lateral approaches or posterior approach- Hip Pain 10% 26% 25% 23%
es with capsular repair reduce the dislocation rate, as does the (8.0, 12.4) (24.7, 27.3) (17.7, 34.1) (19.7, 26.7)
use of larger heads. Constrained liners are not needed. Large Walking without Aids/ 31% 15% 72% 54%
multi-center trials are necessary before many of these contro- Good Function (27.8, 34.4) (14.0, 16.1) (62.8, 79.7) (49.8, 58.1)
versies can be legitimately settled. (within 2 years)

STUDY OUTCOMES: THA VERSUS HEMI-ARTHROPLASTY ** The raw numbers were not available for calculation of the confidence intervals.
Author % Re- WI Dis- DVT % % Therefore, the CIs are based on the percentage in the table and the total sample
size presented at the top of each column. (All CIs in the first column are based on
Mortality operation location Pain Function
N=746, all in the second column are based on N=4530, etc.)
1yr >1yr % (none, (good)
minimal)
Keating (2005)
BHA 9 16 6 4 3 0 39 43
THA 6 9 9 4 4 6 43 48
Ravikumar (2000)
HA 27 86 21 7.4 7.4 13 46 66
THA 23 81 15 3.3 3.3 20 67 73

WI=wound infection, DVT=deep venous thrombosis, THA=total hip arthroplasty,

BHA=bipolar hemi-arthroplasty, HA=hemi-arthroplasty

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
342 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 343

WHAT IS THE OPTIMAL INTERNAL FIXATION FOR FEMORAL

NECK FRACTURES?
Mohit Bhandari, MD

Multiple Cancellous Screws: gical mortality, arthroplasty reduced the need for revision sur-

SYMPOSIA TRAUMA
Advocates of multiple cancellous screws focus upon superior tor- gery (relative risk 0.23, 95% confidence interval, 0.13 0.42,
sional stability, limited disruption of femoral head blood supply, homogeneity p<0.01). We explored the reason for variability in
and minimally invasive of insertion. Based on physiologic and study results and found that arthroplasty appeared to decrease
observational studies, most surgeons use 3 parallel cancellous the risk of revision far more when the internal fixation was done
screws in a triangular (typically inverted) orientation. using screws alone (relative risk 0.11) than when internal fixa-
Proponents of cancellous screws further argue that small diame- tion was conducted using a compression screw and side plate
ter screws retain more viable bone after insertion than larger slid- (0.59) (p-value on difference in estimates < 0.01.
ing hip screws. Retaining more cancellous bone optimizes vas-
Head to head comparisons provide some support for this indi-
cularity and thus may reduce the risk of avascular necrosis of the
rect evidence. To further explore the evidence for alternative
femoral head. A randomized trial comparing three cancellous
internal fixation techniques, in femoral neck fractures we con-
screws with a larger sliding hip screw found a 3.5-fold greater
ducted a comprehensive search of the literature. We conducted
femoral head vascularity at follow-up bone scanning with screws
database searches of Cochrane Library, Medline, and EMBASE to
(Madsen). Surgeons can insert cancellous screws using 3 small
find potentially relevant articles. Two of us screened 416 poten-
stab incisions with limited blood loss and operating time.
tially eligible titles and abstracts and retrieved 298 full text
papers. An additional 12 studies were identified from review of
Sliding Hip Screws
the bibliographies of retrieved articles. Among these, we identi-
Although cancellous screw fixation improves torsional strength,
fied 4 meta-analyses and 58 randomized trials that provided
implant failures typically occur with bending and vertical shear
information on surgical treatments for femoral neck fractures.
loads (i.e.,, with weightbearing). The sliding hip screw, the gold
standard approach in treating inter-trochanteric fractures of hip, A meta-analysis by Parker and colleagues evaluated 28 trials
has gained popularity as an alternative in the management of (N=5547 patients) and reported no advantage of any internal
femoral neck fractures. Proponents of the sliding hip screw fixation technique over any other. The trials were small (range
believe its superior biomechanical properties and greater frac- in sample sizes: 33-410), and methodologically limited. Only 5
ture stability in osteoporotic bone should decrease the need for RCTs evaluated sliding hip screws versus cancellous screws (4
revision surgery. Sliding hip screw constructs have shown two- displaced femoral neck fractures, 1 undisplaced femoral neck
fold greater maximal strength and less displacement under fractures). These trials ranged in size from 33-209 patients and
physiologic loading conditions compared to screws. In cadaver- have few total outcome events (range: 3-34 events). All studies
ic model, the sliding hip screw performed better than cancellous concluded ‘no differences’ between implants; however, in all
screws in stabilizing unstable femoral neck fracture under cyclic studies, the point estimate of effect favored sliding hip screws.
loading. The sliding hip screw performed better in osteoporotic The pooled estimate shows a trend in favor of the sliding hip
bone and was less sensitive to decline in bone mineral density screw in reducing the need for revision surgery (RRR=27%,
than screws. Newer minimally invasive techniques allow sliding 95%CI: 48%, -4%, P=0.08).
hip screws insertion with small incisions and smaller sideplates
In summary, both indirect and direct comparisons suggest a
with limited blood loss and operating times.
possible benefit for a sliding screw over multiple cancellous
In summary, experimental data suggest that cancellous screws screws in reducing the need for revision surgery. The indirect
offer greater preservation of blood and supply while sliding hip nature of the comparison from the meta-analysis of arthroplas-
screws provide greater biomechanical stability to bending stress- ty versus internal fixation, and the small sample sizes, method-
es. While both arguments are persuasive, the impacts of these ological limitations, and non-significant pooled estimate from
biologic alterations on outcomes that are important to patients the direct comparisons, leaves the issue very much in doubt.
offer more compelling guidance for clinical practice.

Impact of Multiple Screws versus Sliding Screw on Revision

Surgery Rates:
We conducted a systematic review and meta-analysis comparing
arthroplasty to internal fixation in patients with displaced
femoral neck fractures. We found that while it may increase sur-

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
343
SYM 07:Layout 1 1/12/07 11:41 AM Page 344

SLIDING HIP SCREW VS. IMHS

FOR INTERTROCHANTERIC FRACTURES
Michael R. Baumgartner, MD
SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
344 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 345

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
345
SYM 07:Layout 1 1/12/07 11:41 AM Page 346

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
346 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 347

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
347
SYM 07:Layout 1 1/12/07 11:41 AM Page 348

USE OF BONE SUBSTITUTES: WHAT IS THE EVIDENCE?

Antonio Moroni, MD
SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
348 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:41 AM Page 349

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
349
SYM 07:Layout 1 1/12/07 11:42 AM Page 350

SYMPOSIA TRAUMA

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
350 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:42 AM Page 351

CONTROVERSIES IN THE MANAGEMENT OF

LONG BONE METASTASES (G)

SYMPOSIA TUMOR
Moderator: J. Sybil Biermann, MD, Ann Arbor, MI (n)

In a debate format, presenters will cover state of the art knowledge regarding surgical
intervention for long bone metastases including current management controversies.

I. Controversy: Closed Vs. Open Treatment for Pathologic Femur Fractures and
Impending Fractures
A. Femur: Closed treatment: non-operative or intramedullary nailing without opening
the fracture site
Albert Aboulafia, MD, Baltimore, MD (n)

B. Femur: Fracture site must be opened:

Edward Cheng, MD, Minneapolis, MN (a - Biomet, Wright Medical Technology)

II. Controversy: Closed Vs. Open Treatment for Pathologic Humerus Fractures and
Impending Fractures
A. Humerus: Closed treatment: nonoperative or closed IM nailing of pathologic or
impending fracture
William Ward, MD, Winston-Salem, NC (e - Smith & Nephew)

B. Humerus: Fractures must be opened

Michael Mott, MD, Warren, MI (n)

III. Controversies in the Management of Spine Metastases

Michael Yaszemski, MD, Rochester, MN (n)

IV. Panel Questions and Case Controversies

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
351
SYM 07:Layout 1 1/12/07 11:42 AM Page 352

CLOSED TREATMENT IS PREFERRED TO OPEN TREATMENT FOR

PATHOLOGIC FEMUR FRACTURES AND IMPENDING FRACTURES
Albert J. Aboulafia MD

Statement: Closed Treatment is preferred to open treatment for c. High incidence of failure of fixation
pathologic femur fractures and impending fractures in the vast d. Cement is not a good substitute for bone
SYMPOSIA TUMOR

majority of cases. Closed treatment offers many advantages

V. Intramedullary Fixation:
compared to open treatment including fewer complications and
a. Point: Do not need to open fracture
predictable results.
i. Cement is not cytotoxic Does not improve local con-
Early Concession: In rare cases, i.e. periarticular lesions, under trol
specific circumstances, open treatment may be indicated. ii. Cancer patients at particular risk for wound complica-
tions
I. Introduction: iii.Minimizes blood loss
a. Incidence and Location of femoral metastases iv. May proceed with immediate XRT
b. Indications for operative and non-operative treatment v. Choice of implant dependent on:
1. Location, Location and Location Diaphyseal/
II. Nonoperative Treatments
Metaphyseal/Epiphyseal
a. Bisphosponates (Breast CA, Prostate CA)
2. IM nails: Antegrade/Retrograde/Recon
b. Investigational Treatments
3. Cement or no Cement?
i. Radiofrequency Ablation (RFA)
a. Risk vs. Benefit
ii. Percutaneous Cementoplasty
b. IM Nail vs. Endoprosthesis
iii.Cryoablation
4. Newer extramedullary implants (locking plates)
iv. Radiation (Conventional/Cyberknife)
VI. Conclusion:
III. Operative Management
The treatment of choice for pathologic fractures and impend-
a. Location, Location, Location (Head, Neck, Metaphyseal
ing fractures of the femur involves closed IM nailing in the
vs. Epiphyseal)
vast majority of cases. Open procedures offer greater risks
b. When to open and when not to open: How to decide?
than closed procedures with little or no benefit.
IV. How the treatment of Pathologic Fractures Differs from
Traumatic Fractures:
a. Less likely to heal (Biologically different)
b. Immediate and long term goals are different

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
352 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:42 AM Page 353

METASTATIC CA TO FEMUR:
OPEN TREATMENT AND PLATING IS PREFERRED
Edward Y. Cheng, MD

Goals No clinical diff in mortality w/ unreamed & reamed nails

• Improve quality of life • England, n =73 (43 reamed, 30 unreamed) femora, 65 pts

SYMPOSIA TUMOR
— Reduce pain, improve function • Mortality 2.7%
• Extend lifespan • No diff in mortality or morbidity
• Promptly resume other tumor treatments — Cole AS, Injury 2000;31(1):25-31
• Immediate, rigid/stable, durable reconstruction for remain- • No diff in IM pressure, in vitro, non-metastatic studies
ing lifespan — Heim D, J Trauma 1995;38(6):899-906
— Avoid progressive tumor osteolysis — Heim D, Injury 1993;24 Suppl 3:S56-63
— Avoid loss of fixation
• Fracture healing is not a goal Stress to lung: ↑ w/ rods than plates
• In vivo dog study
Pros of plating • Fat emboli induced, then fracture fixed @ 4 hrs and 24 hrs
• Obtain tissue for biopsy later by either plate, reamed rod, unreamed rod.
• Excise tumor and reduce time to tumor regrowth/osteolysis • alveolar-arterial pO2 gradient: One hour after surgery, A-a
• More rigid, superior pain relief, allows immediate motion pO2 gradients = four (p < 0.05, reaming) and 3.5
• Avoids joint related morbidity (unreamed) times higher for rods than for plate fixation
• Less stress to lung • No diff in pulm edema or fat in lung
• Lower mortality
No ↑ ARDS w/ rods vs. plates in thoracic injury & femur fx
Pros of IM rods • Retrospective case comparison
• Less dissection • 117 IM reamed rods, 104 plates
• Protects entire bone • No diff in pneumonia, PE, multiple organ failure, or death
• Less blood loss • May or may not apply to met CA setting
Technique Reaming causes subclinical marrow fat emboli
• Open fx site, use sterile tourniquet if possible • Confirmed by transophageal echocardiogram studies – in
• Curette tumor thoroughly (thru fx site if displaced, or make vivo...
cortical window) • Does tumor cell emboli occur too?
• Reduce fx and fit plate to bone • Does reaming hasten pulm metastasis and death?
• Insert screws proximally & distally – provisional fixation
• Pre-drill screw holes around tumor cavity Plates provide more immediate rigid fixation in prox, dia-
• Inject zometa impregnated PMMA (thru window and screw physeal and supracondylar femur fx’s
holes) narrow tube nozzle for cement gun 1. Prayson MJ, Mechanical comparison of endosteal substitu-
• Insert remaining screws partially tion & lat plate in supra femur fx. J Orthop Trauma 2001
• Final tightening only after PMMA hardened 2. Meyer RW, Mechanical comparison of dist fem side plate
• Check stability and joint ROM and retrograde IM nail. J Orthop Trauma 2000
3. Kummer FJ, IM vs extramedullary fixation of subtroch fx.
Plates vs IM rods for met CA Acta Orthop Scand 1998
Medline search, 1950 – 2006 4. Koval KJ, Distal femoral fixation: lab comparison of 95
• Level I and Level II, none degrees plate, antegrade and retrograde reamed IM nails. J
• Level III Orthop Trauma 1996
— Dijkstra S, fx humeral shaft: comparison of IM locking 5. Firoozbakhsh K, Mechanics of retrograde nail vs plate for
nail vs plate w/ PMMA. Europ J Surg Oncol supracondylar fem fx. J Orthop Trauma 1995
1996;22(6):621-6. 6. Tencer AF. Biomechanical comparison of various methods
• Level IV of stabilization of subtroch fem fx. J Orthop Res 1984
— IM rods : 15 studies
— Plates : 3 studies Recommendation
• Level V • Open and excise tumor
— Expert opinion • Use plate w/ PMMA for fixation
— Superior rigidity and pain relief
Lung complications w/ IM rods — Less physiologic stress to lung
• Norway, n= 45 reamed nails, 43 pts — Lower mortality
• Acute ↓O2 sat or ↓BP = 11/45 (24%) • Reserve IM nailing for bone w/ diffuse, tumor involving
• Death 3/45 (8%) multiple lesions within bone
• > 10 papers in literature discussing sudden death and fat
emboli to lung w/ IM nailing in met CA setting

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
353
SYM 07:Layout 1 1/12/07 11:42 AM Page 354

METASTATIC DISEASE OF THE HUMERUS:

THE CASE FOR IM NAILS
William G. Ward, MD

20% of mets occur to UE½ of these – humerus Caveats

--Proven mets
SYMPOSIA TUMOR

The Big Four

Don’t nail a chondrosarcoma
Breast
• Complete history, physical exam, complete work-up
Lung
• Check for prior anticoagulation meds
Kidney
• No medical contra-indication to surgery
Prostate
• No recent WBC/platelet depleting immunosuppressive
GOALS chemotherapy.
• Pain Relief
General Guidelines – Fractured
• Function
• Needs internal fixation (IM nail)
• “Cure” Rarely
• Plus adjuvant therapy (RT, Chemo, hormone, etc)
Assumptions
General Guidelines “Impending Fractures”
• Fracture
• Co-existent LE Mets plus impending fracture humerus
• Impending fracture
• More inclinced to nail: need arms for crutches, canes, walk-
• Debilitating pain
er, etc.
• Unresponsive to RT
Isolated Humerus Mets
Nike Approach
• Renal cell carcinoma: resect, endoprosthetic reconstruction
(Devil on the Shoulder)
• Breast: purely lytic: IM nail & RT
If:
— Mixed lytic/blastic- RT (+) IM Nail
• It needs fixation
• Lung: usually lytic: IM nail & RT
• IM Nail provides reasonable biomechanical solution
• Prostate: sclerotic: RT for pain, chemo and/or hormone
Just Do It
therapy (no surgery.
Angel on the Shoulder — No surgery
If: — Lytic: IM nail & RT
• It doesn’t need fixation or • Myeloma: IM nail & RT & Chemo
• IM Nail will not provide reasonable biomechanical solution • Lymphoma: IM nail & RT & Chemo
Don’t Do It
Moderate to Extensive Metastatic Disease Elsewhere
Other Factors • Renal cell metastases – IM Nail & RT vs. resection – depends
• Underlying disease on anatomy, individual factors
• Diagnosis • Breast carcinoma, myeloma, lymphoma, prostate carcino-
• Extent of lesion ma:
• Extent of disease elsewhere — Pure lytic – IM nail plus RT
• Patient’s overall status — Lytic & Blastic – RT, (+) IM Nail
• Longevity — Sclerotic – RT & chemo
• Patient’s needs — Lung cancer – IM Nail & RT
• Patient’s desires
Limited Disease Elsewhere
Nail vs. Plate • Individualized therapy
• Nail protects greater length of bone • RT responsive – RT + surgery
• Nail requires far less dissection • RT unresponsive – Surgery ± adjuvant
• Nail causes less bleeding – rarely need embolization for — IM Nail
RCCA with IM Nail — Occasional resection
• Nail technically easier
IM Nail Candidate: Lesion from lower humeral neck to
• Nail biomechanically superior
within 4-5cm of olecranon fossa
Damron et al CORR 363: 1999 – IM Nail
• Provides greater energy absorbed to failure and better stiff- IM Nail Technique
ness than plate fixation. • Lateral position
• Reversed table
Inadequate Treatment Results In:
— Anesthesia at foot of table
• Fractures
— Circuit extension
• Pain
— C-Arm over top
• Poor Function
• Requires system with distal targeting jig
• Poor ability to withstand future challenges (i.e. bony mets
• Percutaneous StartAnterior border of acromion
to LE)
• View humerus on AP-cross table C-arm
• Harder to heal a pathologic fracture than to prevent one
• Assistant applies longitudinal traction
• Non-union after TR and bone deficiency
• Manipulate humerus with left hand (A-P positioning)
• Stab incision in line with rotator cuff fibers
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
354 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:42 AM Page 355

• Guide pin superior lateral portion of head High functioning patient – extend skin incision – suture
• Initiating reamer – entry site rotator cuff slit
• Guide wire across fracture/lesion
Typical functioning patient with mets – (+) suture to cuff,
• Ream
close skin.
• Nail length
— as long as possible Post-Op IM nailing humerus
— be sure tip buried proximally • Pendulum exercises immediately
• Distal interlocks • Sling prn comfort
— Outrigger for location (be sure nail head is buried) • No lifting

SYMPOSIA TUMOR
— 4 cm lateral incision – watch for radial nerve (especially • Avoid opening heavy doors, etc.
if nail tip not near olecranon fossa) • Rotator cuff rehab protocol for daily living activities as tol-
— Lateral septum – determine AP dimension of humerus erated.
— center guide
WGW #’s
— drill proximal interlock first (of distal interlocks)
• 1991-2002
— can “peer” through hole if hit metal.
• 327 Mets treated surgically; 68 involved humerus (21%)
— “Encourage” or redirect drill point prn
WGW – 68 Humerus mets Treated Surgically
— Place screw
1991-2002
— Drill distal hole (leave proximal screw drill guide hooked
IM Nails (interlocked) 25
on screw head) assures perfect alignment of distal inter-
Endoprostheses 20
lock drill.
Plate fixation 11
— Check screw lengths with C arm
Rush Rods or Enders (PMMA) 5
• Proximal interlocks
Combo (Rush/Ender & plate) 3
— Use 3-4 screws prn
Amputation 3
— Inferior neck, lateral to medial, bicortical gives best fixa-
Resection (Tinkor Linberg) 1
tion
— Superior lateral screw (unicortical – modest fixation at
best)
— Redirect jig – AP screws – Can give moderate bicortical
fixation – “judge length by feel, c-arm, length of lateral
screws – less satisfying

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
355
SYM 07:Layout 1 1/12/07 11:42 AM Page 356

CONTROVERSIES IN THE MANAGEMENT

OF LONG BONE METASTASES
Michael Mott, MD

The HUMERUS—The Case for open (plate fixation) manage- 4. Cement

ment a. Useful with significant bone loss
SYMPOSIA TUMOR

b. Effectively lock the implant to the reconstruction

1. Fracture Prediction
c. Caution nerve locations and large boluses
a. Inexact Science
b. Most Humeri pathologic lesions present with fracture 5. Tumor treatment
(already) present a. Gross Debulking if Present
b. Pretreatment for Vascular Metastases—e.g. Renal,
2. Anatomic Considerations
Hepatocellular
a. Location of Metastases
c. Adjunctives possible/may be limited by anatomic consid-
b. Bone Anatomy
erations
c. Torsional Stresses
d. Post-operative XRT for (nearly) all
d. Not typically “weight-bearing”
e. Bisphosphonates
e. Shortening not “major” concern
6. Analogous to Traumatic Fractures
3. Fixation Options
a. Less shoulder pain
a. Proximal/ Distal Most Lesions
b. Improved resistance to torsional loading
i. Dependent on bone quality
c. Less chance for nerve incarceration
ii. If Unreconstructible – ?Replacement
d. Proximal/distal ends with poor bone quality--
b. Diaphyseal /Metadiaphyseal Lesion
?Replacement
i. Plate with Large Fragment Plate
ii. Maximize plate length & cortices above /below lesion
iii.Locking plates can expand fixation options
iv. Shortening &/or Cement Augmentation, Indirect
Reduction helpful

REFERENCES • Schurmann M, Gradl G, Andress H-J, Kauschke T, Hertlein H, Lob G. Metastatic

• Anderson JT, Erickson JM, Thompson RC Jr, Chao EY. Pathologic Femoral Shaft Lesions of the humerus treated with the isoelastic diaphysis prosthesis. CORR
fractures comparing fixation techniques using cement. CORR 1978; 131:273-78 2000; 380: 204-214.

• Damron TA, Rock MG, Choudhury SN, Grabowski JJ, An KN. Biomechanical • Srinivasan K, Agarwal M, Matthews SJ, Giannoudis PV. Fractures of the distal
analysis of prophylactic fixation for middle third humeral impending pathologic humerus in the elderly: Is internal fixation the treatment of choice? CORR 2005;
fractures. CORR 1999; 363: 240-48. 434:222-230.

• Dijkstra S, Stapert J, Boxma H, Wiggers T. Treatment of pathological fractures of • Tome JL, Carsi B, Garcia-Fernandez C, Marco F, Stern LLD. Treatment of patho-
the humeral shaft due to bone metastases: a comparison of intramedullary lock- logical fractures of the humerus with Seidel nailing. CORR 1998; 350: 51-55.
ing nail and plate osteosynthesis with adjunctive bone cement. Eur J Surg Onc • Vail TP, Harrelson JM. Treatment of pathologic fracture of the humerus. CORR
1996; 22(6): 621-26. 1991; 268: 197-202.
• Flinkkila T, Hyvonen P, Lakovaara M, Linden T, Risteniemi J, Hamalainen M. • Ward WG, Holsenbeck S, Dorey FJ, Spang J, Howe D. Metastatic disease of the
Intramedullary nailing of humeral shaft fractures – a retrospective study of 126 femur: surgical treatment. CORR 2003; 415S: 230-44.
cases. Acta Orthop Scand 1999; 70(2): 133-36. • Yazawa Y, Frassica FJ, Chao EYS, Pritchard DJ, Sim FH, Shives TC. Metastatic
• Frassica FJ, Frassica DA. Evaluation and treatment of metastases to the humerus. bone disease: a study of the surgical treatment of 166 pathologic humeral and
CORR 2003; 415S: 212-18. femoral fractures. CORR 1990; 251: 213-19.
• Ikpeme JO. Intramedullary interlocking nailing for humeral fractures: experience • Srinivasan K, Agarwal M, Matthews SJ, Giannoudis PV. Fractures of the distal
with the Russell-Taylor humeral nail. Injury 1994; 24(7): 447-55. humerus in the elderly: Is internal fixation the treatment of choice? CORR 2005;
• Jacofsky DJ, Papagelopoulos PJ, Sim FH. Advances and challenges in the surgical 434:222-230.
treatment of metastatic bone disease. CORR 2003; 415S: 14-18. • Berenson JR, Rajdev L, Broder M. Treatment Strategies for Skeletal Complications
• McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. of Cancer. Cancer Biol Ther. 2006. Sep 20;5(9)
Fixation of fractures of the shaft of the humerus by dynamic compression plate • Coleman RE. The role of bisphosphonates in breast cancer. Breast. 2004 Dec;13
or intramedullary nail. J Bone Joint Surg Br 2000; 82B(3): 336-39. Suppl 1: S19-28 Review
• Modabber MR, Jupiter JB. Operative management of diaphyseal fractures of the • Lipton A, Colombo-Berra A, Bukowski RM, Rosen L, Zheng M, Urbanowitz G.
humerus – plate versus nail. CORR 1998; 347: 93-104 Skeletal complications in patients with bone metastases from renal cell carcino-
• Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of ma and therapeutic benefits of Zoledronic Acid. Clin Cancer Res 2004 Sep 15;
pathological fractures of the shaft of the humerus. J Bone Joint Surg 1996; 78(6): 10 (18 pt 2):6397S-403S. Review
891-96.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
356 page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
SYM 07:Layout 1 1/12/07 11:42 AM Page 357

SYMPOSIUM DEBATE:
RADIATION THERAPY SHOULD BE THE FIRST LINE OF
TREATMENT FOR METASTATIC DISEASE OF THE SPINE
Michael Yaszemski MD, Alan M. Levine MD

SYMPOSIA TUMOR
Pro: 2) The cause of pain in patients with spinal metastases can be
1) Most patients with symptomatic lesions of the spine have accurately determined in many patients prior to therapy
radiosensitive tumors and will achieve adequate pain relief using appropriate history, physical examination and diag-
with palliative doses of radiation. nostic studies. This allows those with causes which will not
2) The risk of radiation for a spinal metastases is far less that respond to radiation (instability, fracture etc) to be deter-
that of surgery especially in patients taking newer biologic mined and treated with surgery
agents i. Causes of pain
This evidence based review of the literature is the result of 1. tumor invasion into vertebral body
an organized search of the PubMed database between 1964 2. pathologic fracture
and August 3005 resulting in 1178 articles on spinal metas- 3. instability
tases. The evidence was classified and reviewed for each 4. root compression
subject area and the strength of the recommendation was 5. cord compression
based on the quality of the evidence. 3) Use of radiation in the treatment of spinal metastases
3) In patients with multiple system metastases, use of radia- diminishes the patient’s bone marrow reserve.
tion for treating spinal metastases does not interfere with 4) Current data suggests that the rate of clinically useful neuro-
the chemotherapy regimen for the remainder of the disease logic recovery in patients with myelopathy secondary to
4) Treatment of spinal metastases only improves the quality of neural compression is statistically significantly higher in
remaining life, it does not extend the duration patients who undergo surgery as apposed to radiation
5) In those patients whose tumors do not respond to conven- A prospective randomized, multi-institutional non-blinded
tion radiation and who do not have cord compression can trial of patients with metastatic spinal cord compression
now be treated with stereotactic radiosurgery treated with either surgery followed by radiation or radia-
A series of 48 patients with 60 renal cell metastases to the tion alone. The primary endpoint was the ability to walk
spine treated with single stage stereotactic radiosurgery with with significantly more patients (42/50, 84%) in the surgery
the Cyberknife. 42 of the 60 lesions had previously failed group than the radiation group (29/51 57%). Patients who
external bean radiation. Axial and radicular pain improved failed in the radiation arm losing the ability to walk did not
in 89% of the patients. do as well as those who had surgery primarily
6) The few patients whose pain or neurologic deficits do not 5) The risk of wound complications is higher in those patients
respond to radiation can undergo surgery for instability or who undergo radiation followed by surgery as apposed to
decompression after radiation those who have surgery followed by radiation
6) The rate of neurologic recovery is higher in those patients
Con:
who undergo surgery followed by radiation as opposed to
1) Certain histologic types of tumors respond better to other
those who fail radiation and then undergo surgery.
treatment modalities
This retrospective study of 85 patients divided them into
a. Patients with cord compression secondary to lymphoma
three groups: radiation alone, preoperative radiation fol-
respond predictability to chemotherapy and do not usu-
lowed by surgery and surgery followed by radiation. Wound
ally need radiation
complication occurred in 32% of those having preoperative
b. Patients with spinal metastases from renal cell carcino-
radiation but only 12% of those having postoperative radia-
ma, sarcomas and melanoma have a low rate of response
tion (P<0.05). Maintenance of function was also superior in
and a relatively poor durability of response to radiation.
those undergoing surgery as the first modality.
Other modalities such as surgery and stereotactic radio-
surgery yield better results.

REFERENCES 5. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M,
1. Rades D, Fehlauer F ,Schulte R, etal Prognostic factors for local control and sur- Young B: Direct decompressive surgical resection in the treatment of spinal cord
vival after radiotherapy of metastatic spinal cord compression J Clin Oncol. 2006 compression caused by metastatic cancer: A randomized trial. Lancet
Jul 20;24(21):3388-93 2005;366:643-648.

2. Ryken TC, Eichholz KM, Gerszten PC, Welch WC, Gokaslan ZL, Resnick DK: 6. Wise JJ, Fischgrund JS, Herkowitz HN, Montgomery D, Kurz LT: Complication
Evidence-based review of the surgical management of vertebral column metastat- survival rates, and risk factors of surgery for metastatic disease of the spine. Spine
ic disease. Neurosurg Focus 2003;15:E11. 1999;24:1943-1951

3. Gerszten PC, Burton SA, Ozhasoglu C, Vogel WJ, Welch WC, Baar J, Friedland 7. Ghogawala Z, Mansfield FL, Borges LF: Spinal radiation before surgical decom-
DM.: Stereotactic radiosurgery for spinal metastases from renal cell carcinoma. J pression adversely affects outcomes of surgery for symptomatic metastatic spinal
Neurosurg Spine 2005;3: 288-295. cord compression. Spine 2001;26:818-824.

4. King GJ Kostuik JP,McBroom RJ, Richardson W. Surgical management of

metastatic renal carcinoma of the spine. Spine. 1991 16(3):265-71.

◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv. The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
357
SYM 07:Layout 1 1/12/07 11:42 AM Page 358

Call for
Abstracts
Applications to submit a poster presentation,
podium presentation, scientific exhibit or multimedia
education presentation are available on-line at

Click on Annual Meeting, 2008 Abstract Submissions

Submission deadline is June 4, 2007

Submission deadline for multimedia education
presentation is July 15, 2007

March 5 – 9, 2008
San Franciso, California

358
PPSE 07:Layout 1 1/12/07 1:40 PM Page 359

AAOS COMMITTEES
SCIENTIFIC EXHIBITS women and 10 million American men currently have
osteopenio or osteoporosis. Associated osteoporotic hip frac-
tures cost the economy $13 billion in 1997 and is expected to
soar to $240 billion by the year 2050. Primary osteoporosis is
SCIENTIFIC EXHIBIT NO. SE69 preventable and treatable. Effective and safe pharmacological
Safety of Musculoskeletal Allograft Tissue therapies exist to treat osteoporosis.
AAOS Committee on Biological Implants
Michael J Joyce, MD, Cleveland, OH SCIENTIFIC EXHIBIT NO. SE71
(a – American Association of Tissue Banks (AATB), Developing the Clinician Scientist
Musculoskeletal Transplant Foundation (MTF)) AAOS Research Development Committee
Scott D Boden, MD, Atlanta, GA Sean P Scully, MD, PhD, Miami, FL (n)
(a, b, e – Medtronic, a, b – Osteotech) Gunnar B J Andersson, MD, Chicago, IL (n)
Scott A Brubaker, BSc, Mc Lean, VA Denis R. Clohisy, MD, Minneapolis, MN (n)
(e – American Association of Tissue Banks (AATB)) This effort is in response to the decreasing ranks of orthopaedic
Christine S Heim, BSc, Mentor, OH (n) surgeon scientists over the past two decades. It is an effort that is
A Seth Greenwald, DPhil Oxon, Cleveland, OH (n) sponsored by the OREF, AAOS, and ORS and focused on
The Orthopaedic Surgeon has the responsibility to inform targeting talented orthopaedic surgeons in training and encour-
patients about the risks and benefits of using musculoskeletal aging and facilitation their development as surgeon scientists.
allograft tissue in surgical procedures. The surgeon must be This effort has consisted of an annual workshop, a traveling
aware of the current potential for transmitting blood borne fellowship, and one-on-one mentorship by members of the
diseases, e.g. hepatitis, HIV and bacterial infections, etc. The Research Development Committee. The program has been active
exhibit provides an understanding of tissue bank practices in for the past 4 years. During that time, 46 residents have attended
donor screening, serology testing, processing, and, when appli- the annual workshop which covers topics such as collaborations,
cable, secondary sterilization or terminal sterilization. The grants, career development and balance of family and profes-
historical record of disease transmission is presented and the sional life. This has the additional advantage of placing surgeon
outstanding safety record associated with the use of allograft scientists in an informal setting with the aspiring residents to
tissue is outlined. Progressive governmental regulatory oversight, develop mentorship relationships. The traveling fellowship has
standards, and a national voluntary accreditation program are supported 9 fellows. These orthopaedic scientists have identified
mentors and laboratories that would most benefit their career

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AAOS COMMITTEES

reviewed. The exhibit also demonstrates that the use of human
allograft tissue is predicated on the gracious altruistic gift from development and than have been afforded the opportunity to
the donor/donor family to the patient recipient. visit these centers. The feedback from both surgeon scientists
and residents has been overwhelmingly positive in terms of the
SCIENTIFIC EXHIBIT NO. SE70 educational and interpersonal outcomes. Several have moved
forward to collaborate on research with their mentors. The
Fragility Fractures and the Orthopaedic Surgeon impact of this program remains difficult to quantify since many
AAOS Women’s Health Issues Advisory Board of the recipients are in the latter stages of their training. The
James R Slauterbeck, MD, Burlington, VT (a – NIH, OREF) development of the participants will continue to be monitored
Mary I O’Connor, MD, Jacksonville, FL to determine the impact this program has on formation of the
(a – DePuy; c – Zimmer) next generation of surgeon scientists. The Research Development
Ann Babbitt, MD, South Portland, ME Committee directly interfaces with the NIH regarding funding
(e – Lilly, Merck, Aventis, Roche; Kyphon) for musculoskeletal research to complement the efforts of
Clinician Scientist Development Program.
Barbara Jean Campbell, MD, Somerset, PA (n)
John D Kaufman, MD, Santa Clarita, CA (n) SCIENTIFIC EXHIBIT NO. SE72
Elizabeth A Ouellette, MD, Miami, FL (n)
Introduction to the AAOS EBP Portal on
Sally A Rudicel, MD, Boston, MA (e – Wyeth)
Leigh Callahan, PhD, Chapel Hill, NC (n) Orthopaedic Knowledge Online: Welcome to the
Barbara D Boyan, PhD, Atlanta, GA (n) Future of Orthopaedic Practice
The WHIAB scientific exhibit, Fragility Fractures and the AAOS Evidence-Based Practice Committee/Guidelines
Orthopaedic Surgeon, seeks to educate orthopaedic surgeons on Oversight Committee
the significance of gender differences in musculoskeletal condi- Michael J Goldberg, MD, Seattle, WA (n)
tions, specifically osteoporosis, by encouraging the incorpora- Michael P Dohm, MD, Grand Junction, CO (n)
tion of bone density scans and other preventative/diagnostic This scientific exhibit promotes and features the new EBP Portal
measures into clinical visits and general patient care to prevent on Orthopaedic Knowledge Online. The portal provides a clin-
osteoporotic fragility fractures. Osteoporosis is a generalized ical-reasoning based educational tool on evidence-based prac-
skeletal disorder or low bone mass and deterioration in micro- tice—on topics from analyzing evidence to outcomes to
architecture causing susceptibility to low energy fractures. evidence-based practice guidelines and performance measures,
Osteoporosis can cause pain, deformity, dependency, depres- levels of evidence, guideline workgroups, clinical quality
sion, create a fear of falling, and even cause premature death. improvement, etc. The OKO EBP portal will help AAOS Fellows
There is urgency for intervention. Over 28 million American

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
359
PPSE 07:Layout 1 1/12/07 1:40 PM Page 360

be prepared for the brave new world of quality-based purchasing devices) products will be compared and contrasted. The finan-
in medicine. This exhibit will feature a live version of the EBP cial markets including self-financing, friends and family, angel
OKO portal along with instructional visual aids and several free investing, venture capital investment and public financing via an
giveaways of software and pocket learning tools. IPO (initial public offering) play an important yet often unrec-
ognized role in clinical device and drug development and the
SCIENTIFIC EXHIBIT NO. SE73 terminology will be defined. The intent is that this exhibit will
◆Current Trends and Hot Topics in Infection demystify this whole area of orthopedics and perhaps inspire
fellows who are inventors and/or entrepreneurs to move their
Prevention, Treatment and Surveillance million dollar ideas from the backs of napkins into the practice
AAOS Infections Subcommittee of Patient Safety of medicine. It is also intended to garner a respect for the
Terry A Clyburn, MD, Houston, TX (a, b – Biomet) expense and effort involved in providing cutting edge medical
Richard Parker Evans, MD, Little Rock, AR drugs, treatments and devices.
(a – Biomet, b – DePuy, e – 3M)
Paul D Holtom, MD, Los Angeles, CA SCIENTIFIC EXHIBIT NO. SE75
(a, b – Ortho-McNeil, Cubist, Pfizer, b – Merck, Wyeth) Bone Graft Substitutes: Facts, Fictions and
Adelisa L Panlilio, MD, Atlanta, GA (n) Application
The purpose of this exhibit is to educate the Fellowship about AAOS Orthopaedic Device Forum
emerging trends in the prevention, treatment and monitoring of A Seth Greenwald, DPhil Oxon, Cleveland, OH (n)
musculoskeletal infections and infectious diseases that may Scott D Boden, MD, Atlanta, GA (e – Medtronic, Zimmer)
affect their patients and practice. The exhibit will summarize
Victor Goldberg, MD, Cleveland, OH (n)
current evidence-based recommendations with regard to the
prevention of musculoskeletal infections in orthopaedic prac- Michael J Yaszemski, MD, PhD, Rochester, MN (n)
tice. This information will be organized in the format of outside- The increasing use of allograft materials in joint revision and
in as it relates to the preparation for surgical intervention tumor surgical applications has stimulated an interest in the
through the process of surgery. This information is based on the evolution of bone substitute technologies. Current concerns
current literature and on the recommendations of the Center for regarding the transmission of blood borne disease, donor avail-
Disease Control in the campaign to prevent antimicrobial resist- ability, processing costs and cultural or religious limitations on
ance in the healthcare setting. Emphasis is placed on the proper the use of allograft materials are further reasons for this interest.
selection and timing of antibiotics in the changing environment This exhibit provides a continuous update of the emergence of
and emerging resistance of infectious agents. Infection as a bone graft substitutes inclusive of growth factors, biologic scaf-
complication of the treatment of musculoskeletal injury and folds and platelet gels. Differentiating these products in terms of
disease remains a significant concern. Currently, orthopaedists their ability to promote osteoconduction and osteoinduction
base practice standards on personal experience, prior teaching provides for an appreciation of their utility. Through physical
description and direct clinical application they are viewed as
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AAOS COMMITTEES

and an extensive body of literature. This literature varies widely

in levels of evidence. We have reviewed this literature and sought alternatives and supplements to allograft and autograft tissue.
to grade the level of evidence in order to make evidence-based Their advantages and caveats are described through clinical
recommendations. We have used CDC guidelines and recom- example and their future potential as a drug-delivery system
mendations in formulating these recommendations. Our discussed. This exhibit continues to report the rapid change in
exhibit provides an overview of these recommendations related the availability of these materials.
to preoperative assessment, intraoperative prophylaxis, and
postoperative treatment and surveillance. We believe these
recommendations will assist the practicing orthopaedist in the
prevention, recognition and treatment of infection.

SCIENTIFIC EXHIBIT NO. SE74

Orthopaedic Innovation: Bench, Bedside, and Bank
AAOS Biomedical Engineering Committee
Stephen Paul Makk, MD, MBA, Louisville, KY
(d – Pradama, Healthgrades, b – DePuy, e – Smith Nephew)
A Seth Greenwald, DPhil Oxon, Cleveland, OH
(a – multiple corporate support)
This scientific exhibit demonstrates pathways, including
patenting, financing and FDA clearance, by which innovative
medical products reach clinical markets. It is built on the suppo-
sition that many physician fellows have million dollar ideas yet
they lack the basic understanding of the mechanisms that allow
them to become products in the medical marketplace. Graphics
facilitate the understanding of the subject matter and they will
be supplemented by multimedia featuring advice from industry
experts. Intellectual property protection, the patent process, and
the different types of patents will be presented and explained.
The FDA process including steps (phases) and their significance
in reach milestones toward PMA (pre-market approval) and 510-
K (devices that piggyback on the prior FDA approval of similar

360 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 361

A D U LT R E C O N S T R U C T I O N H I P
PAPERS possibly osteoinductive properties of trabecular metal and the
possibility of bridging of gaps up to 5 mm. During 1998, 82
consecutive patients (86 hips) underwent primary THA using
the elliptical press-fit trabecular metal monoblock cup (TMT,
PAPER NO. 016 Zimmer) by the senior author. Patients were followed up at 6,
Uncemented Porous Tantalum Acetabuli: Clinical 12, 24 weeks, 12 months and annually thereafter to a minimum
Follow-up, and Radiographic Review of 1212 Cases of seven years. Defined radiographic study was performed. EBRA
method, which contains an algorithm that excludes radiographs
William Long, MD, New York, NY (n)
exceeding the limits of patient positioning errors was used, thus
Nicolas Noiseux, MD, Rochester, MN (n) avoiding preanalytical errors. All hips were followed up for mean
Tad Meredith Mabry, MD, Rochester, MN period of 7.3 years. No patient was lost to follow up, no cup was
(a – DePuy, Zimmer, Stryker Howmedica) revised, no radiolucencies and no other complications were
Arlen D Hanssen, MD, Rochester, MN observed. Of the original cohort, 25 hips at the immediate post-
(a – Implex, Zimmer c – Zimmer) operative radiograph had evidence of gap between the outer
David G Lewallen, MD, Rochester, MN (a, b, c – Zimmer) surface of the cup and acetabular host bed, which ranged 1 to 5
Abstract: Uncemented porous tantalum acetabular components mm. These 25 hips were additionally studied for cup migration
became available in July 1997. The purpose of this study was to through 2 years using EBRA method. At 24 weeks post-opera-
determine clinical and radiographic results with this new tively, no acetabular cup with initial evidence of gap had
implant material. Our institutional total joint registry was used migrated and all gaps were filled with bone. Bridging interface
to identify all cases where porous tantalum sockets were used. gaps up to 5 mm using trabecular metal monoblock cup indi-
Clinical outcomes and sequential radiographs were assessed for cates strong osteoconductive and possibly osteoinductive
radiolucent lines, migration, and osteolysis. 1212 cases with 2 to biomaterial properties.
7 year follow-up were identified (613 primaries, 599 revisions).
Porous tantalum implants used included: 388 monoblock cups;
PAPER NO. 018
31 monoblock cups with peripheral screws; and 793 revision Results of a Porous Cup-Cage Construct in
shells, with screws and a cemented liner. 58 re-operations were Complex Acetabular Revision Surgery with Severe
performed (all causes): 16 after primary THA (2.6 percent), and
42 following a revision (7.0 percent). Cup removal was
Bone Loss
performed in 20 cases (7 primaries, 13 revisions). The Nicolas Noiseux, MD, Rochester, MN (n)
commonest cause was septic joint (14). No cups were revised for David G Lewallen, MD, Rochester, MN (a, b, c – Zimmer)
aseptic loosening during the study period. Radiographic review William Long, MD, New York, NY (n)

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

revealed one case of a cup that had moved, though assympto- Catherine Kellett, FRCS (Tr & orth)/Dr, Toronto, ON
matic and another of complete radiolucency which has subse- Canada (n)
quently been revised for sepsis elsewhere. Incomplete Allan E Gross, MD, FRCSC, Toronto, ON Canada
radiolucent lines were present on 14 percent of initial post-oper-
(e – Zimmer)
ative radiographs. At two years, 2/3 of these had resolved. 33
percent persisted (88 percent isolated to zone three). Three Abstract: In revision THA, most hips can be reconstructed with
incomplete lucencies not on post-operative films were seen later, an uncemented hemispherical cup with screws. With severe
involving a single zone and were non-progressive. Initial results acetabular bone loss, antiprotrusio cage reconstruction has
of porous tantalum acetabular components demonstrate low shown satisfactory initial results, but lack of biologic fixation can
reoperation rates, high rates of initial stability and an absence of lead to mechanical failure over time. Combining these two tech-
radiolucencies. Continued follow-up will be of interest in deter- niques may provide a more optimal construct for major acetab-
mining whether these excellent initial results are associated with ular defects. The cup-cage is defined as a porous ingrowth cup
long term durability. with screws and a cage inserted over the top, unitized with a
cemented liner. This study examines early results of this novel
PAPER NO. 017 porous tantalum cup-cage construct. Thirty-one patients with
major acetabular defects underwent revision THA with a cup-
Radiographic Evidence of Acetabular Gap-Filling cage construct. Clinical and radiographic outcomes were deter-
Following THA Using a Trabecular Metal Cup mined at minimum 2 year follow-up. Complications,
George A Macheras, MD, Athens, Greece (n) reoperations and functional status (overall satisfaction, pain,
Athanasios Kostakos, MD, Neo Psyhiko, Greece (n) limp and use of gait-aids) were assessed. Radiographs were
Stephanos Koutsostathis, MD, Athens, Greece (n) analyzed for evidence of implant migration, new radiolucent
lines, and bone graft resorption. Mean follow-up was 28 months
Athanasios Topkas, MD (n)
(range 24-52), excluding 3 deaths before 1 year post-op and 3
Kostas Kateros, MD, Athens, Greece (n) lost to follow-up. Complications included 2 recurrent disloca-
Robert W Eberle, Apex, NC (e – Zimmer) tions requiring revision to constrained liners. Outcomes were 82
Abstract: Survival of cementless acetabular components in total percent excellent or good, 12 percent fair and 6 percent poor.
hip arthroplasty depends on design, manufacturing and initial Radiographically, all the implants were stable and none had
fixation stability. We radiographically identified gaps between migrated. Incomplete radiolucent lines were present around the
host bone and acetabular component dome. The purpose of this ischial flange of the cage in 13 patients. Partial graft resorption
prospective study was to evaluate the osteoconductive and occurred in 8 patients. 29 of 31 patients were ambulatory, with

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
361
PPSE 07:Layout 1 1/12/07 1:40 PM Page 362

none unable to walk due to this hip. Early results of a cup-cage arthroplasty. From July 1991 to December 2000, 567 consecutive
construct in major acetabular bone loss show excellent rates of FIG’s were done at the authors’ institution. Of these, 42 hips in
initial implant stability and satisfactory clinical outcomes. 40 patients (~ age 73.8 y) were performed with the use of stems
220 mm or longer (7.6% of all FIG’s). These were done for
PAPER NO. 019 aseptic loosening in 23 hips (54.7%), acute periprosthetic frac-
◆Average 10 Years Results of Uncemented Cup ture in 8 hips (19%), periprosthetic fracture nonunion in 9 hips
(21.4%), and infection in 2 hips (4.7%). The average number of
Revision with the Reinforcement Devices for Bone revisions prior to this procedure was 1.85 (range 1 to 4). Eighty
Loss percent of the femurs were classified as Endo-klinik 3 or 4.
Tae Hyun Lee, MD, Chiba, Japan (n) Twenty-seven (65%) hips were done without specialized instru-
Chikashi Shirai, Md, Chiba City, Japan (n) ments and 95% of femurs required some form of proximal
Tadao Murata, MD, Chiba, Japan (n) femoral reconstruction. No patient has been lost to follow-up.
Sixteen patients (16 hips) have died at an average of 52 months.
Yoshitada Harada, MD, Chiba City, Japan (n)
The average clinical follow-up for those hips that survived past
Abstract: The optimal technique for acetabular revision surgery 48 months was 90.72 months (7.5 years). Five hips (11.8%) had
in the face of major bone stock deficiency remains controversial. an intraoperative fracture, but only one occurred at the time of
We produced the Murata-Chiba (MC) Support Ring with the impaction. The postoperative major complication rate was 29%.
Harris-Galante II(HGII) cup or the Trilogy cup as acetabular Two postoperative femoral fractures occurred. One occurred
reinforcement device for uncemented fixation in 1993. The MC through a cortical perforation which was inadequately treated at
Support Ring is attached to the HGII, or the Trilogy Cup, with the time of surgery and the second at 12 months from surgery in
one screw, and an upper outside flange and an inside lower hook a patient who sustained a fall. Six patients (6 hips) have required
are used to prevent damage to the auto-bone graft. Between a femoral reoperation (14.6%). The survivorship free from revi-
1993 and the present we have performed 90 cementless acetab- sion hip surgery was 90% ± 0.05 SE at 5 and 10 years and
ular reconstructions using MC Support Rings and auto- and arti- survivorship free from mechanical failure 80% ± 0.06 SE at 5
ficial bone grafts for bone loss. We here report on the average 10 and 10 years. The use of long stems for FIG has been used in the
years outcomes. Fourty-two hips with pelvic bone loss treated most difficult cases with significant loss of bone stock. Our expe-
with acetabular reconstruction using MC Support Rings with rience shows that the surgical procedure is technically chal-
HGII cups were evaluated. They were analyzed clinically (Harris lenging and can have a high intraoperative and postoperative
Hip Score’HHS’) and radiographically after follow-up of 6 complication rate. Although areas of lysis or cortical thinning
to13.5 years (average 10 years). No acetabular component was were bypassed by long stems, areas of cortical perforations
revised due to mechanical loosening. Two hip was removed due should be adequately treated at the time of surgery in an effort
to late infection and due to breakage of locking mechanism.The to reduce the postoperative fracture rate.
patients rated their results as excellent in 9 (22.5%), good in 25
(62.5%) and fair in 3(7.5%). thirty-seven cases (92.5%) were PAPER NO. 021
classified as a clinical success. All autografts had radiographic
evidence of incorporation. Thirty-seven cases(92.5%) were clas-
Survivorship Analysis of an Extensively Porous
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

sified as bone ingrown, 4(7.5%) as fibrous stable . MC Support Coated Stem in Revision THA: Results in 861 Hips
Rings were very useful as acetabular reinforcement devices for Holly J Haight, MD, Rochester, MN
uncemented acetabular revision using auto- and artificial bone- (a – DePuy, Stryker, Zimmer)
grafts for bone loss. The current results encourage the use of the Cathy D Schleck, BS, Rochester, MN (n)
MC suport ring and the porous cup with the autobone grafts for
William Harmsen, MS, Rochester, MN (n)
the acetabular bone loss in revision THA. Further, the use of
these devices for acetabular revision using allograft may also be Daniel J Berry, MD, Rochester, MN
recommended. (a, c – DePuy, a – Stryker, Zimmer)
Abstract: To evaluate survivorship of a single extensively porous
PAPER NO. 020 coated femoral component used for THA revision and deter-
Outcome of Long Cemented Stems Used for mine factors associated with success and failure. From 1992-
2003, 961 consecutive uncemented extensively coated stems of
Femoral Impaction Grafting (FIG) one design were implanted in revision THA in 901 patients, at
Rafael J Sierra, MD, Rochester, MN (n) one institution. 861 hips had minimum 2 year followup. Mean
John Anthony Forsyth Charity, MD, Exeter, United Kingdom age: 66 years; 56% male. Mean followup: 5.1 years (maximum
(n) 12 years). Stem diameters: 10.5-13.5 mm in 215, 15-18 mm in
Andrew John Timperley, MD, Exeter, United Kingdom 647, and 19.5-22.5 mm in 99. Stem lengths: 6’ in 102, 7’ in 121,
(a, b, e – Stryker) 8’ in 425, and 9-10’ in 313. Of the 861 hips, only 36 (4.2%) were
revised. Reasons for revision included aseptic loosening (20),
Graham Allan Gie, MD, Exeter Devon, United Kingdom
infection (9), stem fracture (4), and periprosthetic femur fracture
(a, b, e – Stryker) (3). Five and 10 year survivorship free of stem removal or revi-
Abstract: The incidence of postoperative fractures reported in the sion for any reason were 95.3% and 94.7% respectively. Five and
literature after FIG is approximately 4%. These usually occurred 10 year survivorship free of revision for aseptic loosening were
below standard length stems in an area of weakened bone that 97.2% and 97.0% respectively. There were no statistically signif-
was left inadequately supported. Long stems (220, 240,260 mm icant effects on survivorship of patient age or gender, operative
length) have been in use since 1991 and special instruments diagnosis (aseptic loosening, periprosthetic fracture, or wear),
were designed in 1997 to allow IG throughout the length of the stem diameter or length. This study, in combination with
femur in an effort to reduce this postoperative complication. The previous studies, demonstrates the efficacy of extensively coated
objective of this study is to present the results of long stems stems in revision THA. This is the first study with sufficient
utilized for impaction grafting in femoral revision total hip sample size to allow analysis of effects of patient demographics

362 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 363

and revision indication. This method demonstrates a low re- 96.2% of patients prior to THA. Intra-operative LL equality was
revision rate across a wide range of age groups and operative achieved in 58.3% of patients and limb lengthening (mean =
diagnoses. The most common reason for re-revision was aseptic 6mm, range 1-70mm) occurred in 35%. During the immediate
loosening which occurred in only 2.3% of patients. post-operative period, limb lengthening (mean = 1.9mm, range
1-70mm) was present in 51.6% of patients. At 6 weeks follow-up
PAPER NO. 022 anatomical LLD (mean = 2mm, range 0-54mm) was present in
Projected Economic Burden of Revision THA and only 19.2% of patients. Interestingly 8% of patients with equal
anatomical LL felt that THA had created LLD. At 6-weeks follow-
TKA for Medicare Enrollees in the Next Decade up a total of 7% of patients complained of unequal leg lengths
Kevin Ong, PhD, Philadelphia, PA (n) of whom only 3% had a significant LLD (>2 cm). Asymptomatic
Fionna Mowat, PhD, Menlo Park, CA (n) and unknown LLD may exist in a relatively large percentage of
Edmund Lau, MS, Philadelphia, PA (n) patients prior to THA. Although THA is successful at restoring LL
Khaled J Saleh, MD, Charlottesville, VA (n) equality in a majority of patients, perception of LLD during the
Jordana K Schmier, MA, Alexandria, VA (n) early weeks after THA is a common problem. A majority of the
Steven M Kurtz, PhD, Philadelphia, PA (n) perceived and clinical LLD resolve within 6 weeks of surgery.
Very small number of patients may complain of persistent LLD
Abstract: The projected revision burden of THA and TKA has
following THA.
been reported previously, but potential economic consequences
are still unknown. Retrospective studies have shown increasing PAPER NO. 024
disparity between Medicare reimbursement and hospital
charges. This study quantifies the projected economic burden of The Natural History of Leg Length Discrepancy
revision THA and TKA for Medicare enrollees, accounting for the After Total Hip Arthroplasty
projected adoption of these procedures, changes in procedural Victoria Anne Brander, MD, Chicago, IL (n)
charges and in the patient population. Medicare (1997-2004)
Raju S Ghate, MD, Evanston, IL (n)
and U.S. Census data were incorporated into a Poisson regres-
S David Stulberg, MD, Chicago, IL (n)
sion model to determine the projected economic impact of revi-
sion THA and TKA through 2015 for hospital and surgeon Abstract: Perception of leg length difference (LLD) is a source of
charges and reimbursements, accounting for inflation. Annual patient dissatisfaction and litigation after hip arthroplasty. We
hospital charges for primary THA and TKA were estimated to evaluated 50 patients with primary THA to determine the clin-
increase by 3.5´ to $17.7 billion and by 4.6´ to $41.7 billion, ical significance of radiographic and patient-perceived LLD the
respectively, between 2005 and 2015. Corresponding THA and first year after surgery. Harris Hip Score (HHS), radiographs and
TKA surgical charges were projected to increase by 1.9´ to $1.9 clinical data were obtained before and at 3 and 12 months after
billion and by 2.6´ to $5.1 billion, respectively. Hospital charges surgery. An investigator blinded to clinical data performed radi-
for revision THA and TKA were projected to be $7.1 billion and ographic measurements. Another, blinded to radiographs,
$4.2 billion; corresponding surgical charges were estimated as recorded patient or clinician reports of LLD. HHS pre-opera-
$0.6 billion and $0.3 billion. Historical data showed reimburse- tively was 47.8 (range 23.2-68.1), at 1 month 70.4 (range 43.3-
100) and at 1 year 89.5 (range 42-100). Mean postoperative LLD

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

ments were 32% to 38% of the charges per procedure. Despite
the greater number of projected revision TKA procedures, revi- was 9mm (range -19-32) at one month and 9mm (range -20-33)
sion THA poses a more severe projected economic impact to at one year. More patients perceived LLD at 1 month than at 1
Medicare due the greater charges for each revision THA year (p<0.05). At one month, a difference of >10mm was more
compared to TKA. This study establishes a novel statistical likely to be perceived (p <0.05). Although 19 patients (38%)
framework for combining projections of the number and had LLD >10mm one year after surgery, only 18 % complained;
charges of future surgeries. This information will be useful for this was not statistically different from those without discrep-
policy makers (CMS), hospital administrators, and surgeons ancy who also perceived inequality. There was no correlation
serving the Medicare population. between patient perception and radiographic LLD at one year.
Patients who perceived LLD were more likely to have joint
PAPER NO. 023 contractures, pelvic tilt, or lumbar spine disease. Many THA
patients initially perceive limb inequality which ultimately
Leg Length Discrepancy and Total Hip Arthroplasty resolves. Radiographic measurement of LLD does not correlate
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker) with patient perception at one year. Patients with perceived LLD
Elena Byhoff, BS (n) are more likely to have hip inflexibility or lumbopelvic impair-
James J Purtill, MD, Philadelphia, PA (n) ments. Pre- and postoperative rehabilitation should include
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) aggressive lumbopelvic exercises.
William J Hozack, MD, Philadelphia, PA (e – Stryker)
Richard H Rothman, MD, Philadelphia, PA (e – Stryker) PAPER NO. 025
Abstract: Limb length discrepancy (LLD) following total hip Nonoperative Management, Tenotomy or Acetabular
arthroplasty (THA) can adversely affect an otherwise excellent Cup Revision for Ilipsoas Impingement after THA
outcome. This prospective study investigates the role of patient Rafael J Sierra, MD, Rochester, MN (n)
perception as a source of leg-length complaint, incidence of LLD
Claudio Dora, MD (n)
prior to and following THA, and the effectiveness of THA in
Peter Koch, Bern, Switzerland (n)
correcting pre-operative LLD. 240 consecutive patients under-
going THA at our institution were recruited. Clinical and radi- Abstract: A select group of patients with Iliopsoas impingement
ographic measurement of LL, as well as patient’s perception (IPI) after total hip arthroplasty (THA) with radiographic
regarding LL was recorded prior to THA and at various times evidence of well fixed malpositioned or oversized acetabular
after THA. Intra-operative measurement of LL was also recorded. components were reviewed. The objectives of this study were to
LLD, with a mean of 2.5mm (range 0- 70mm) was present in 1.) Report the natural history of continued conservative manage-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
363
PPSE 07:Layout 1 1/12/07 1:40 PM Page 364

ment for IPI after THA, 2.) Assess the results of surgical treatment PAPER NO. 027
for this condition by either tenotomy or acetabular cup revision 18F-FDG-PET in the Diagnosis of Septic and Aseptic
and 3.) To delineate clinical and radiographic criteria and estab-
lish a treatment algorithm for management of IPI after THA Loosening: Knee Versus Hip Endoprostheses
associated with a prominent acetabular cup. A consecutive series Wolfgang Mayer, MD, Munich, Germany (n)
of 29 patients (30 hips) were reviewed. All patients underwent a Susanne Wagner, MD, Munchen, Germany (n)
trial of conservative management with no improvement in Sonja Maegerlein, MD, Hamburg, Germany (n)
symptoms. Eight patients (8 hips) preferred continued conser- Rainer Linke, MD, Munchen, Germany (n)
vative management (Group 1), and 22 hips underwent surgical Volkmar Jansson, PhD, Munchen, Germany (n)
management with either iliopsoas tenotomy (group 2) or
Peter E Mueller, PhD (n)
acetabular component revision and tendon debridement
(Group 3) based on clinical and radiographic findings. Patients Abstract: Arthroplasty plays a growing role in our society today.
were followed prospectively for at least 2 years (mean: 40±17 Due to scientific and medical progress there are an increasing
(range 24 to 65 months). Conservative management failed in all number of viable candidates and the improvement of quality of
8 hips. Surgical treatment resulted in complete pain relief in 20 life thereafter speaks for itself.Even though the operations are
of 22 hips regardless of type of surgery performed. The Harris largely successful, complications after joint replacement surgery
hip score (HHS) was also significantly better in combined occur frequently. Approximately 10% of lower limb arthroplas-
groups 2 and 3 when compared to those treated in group 1. ties need surgical revision, of which 70% are due to loosening.
Group 3 patients had the best scores of all three groups at last The purpose of this study was to assess the feasibility of 18-fluo-
follow-up. An algorithm for the management of IPI associated rodeoxyglucose positron emission tomography (18F-FDG-PET)
with an overhanging cup has been recommended. Continued in detecting septic and aseptic endoprosthetic loosening of hip
conservative management for IPI universally failed in all and knee endoprostheses. Thirty-three patients (age range: 45 to
patients. Tenotomy of the iliopsoas and revision of the acetab- 90y) with lower limb arthroplasty complaints (74 prostheses)
ular component, both are successful surgical options. Acetabular were studied preoperatively with 18F-FDG-PET. All patients
revision should be performed in young patients with adequate underwent surgery at a later stage with microbiological culturing
bone stock and is associated with complications inherent to the to differentiate aseptic and septic loosening and to confirm the
revision itself. Iliopsoas tenotomy should be performed in older final diagnosis. Prostheses were tested intraoperatively for
patients with limited functional demands and those with well- stability and microbiology The sensitivity/specificity of 18F-
fixed truncated conical shaped cups and if anticipated bone loss FDG-PET towards implant loosening in the hip was 80%/87%,
after revision surgery would be significant. in the knee 56%/82%.The sensitivity/ specificity for infectious
loosening in hip replacement arthroplasties was 67%/83%, in
PAPER NO. 026 the knee 14%/89%. 18F-FDG-PET seems an excellent method
for detecting hip endoprosthetic loosening and a moderate tool
Locking Compression Plates for Vancouver Type B1 to diagnose hip implant infection. It should not be seen as the
Periprosthetic Femoral Fractures method of choice to diagnose knee endoprosthetic loosening
Martin Buttaro, MD, Buenos Aires, Argentina (n) and infection.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

German Luis Farfalli, MD, Cordoba, Argentina (n)

PAPER NO. 028
Marco Paredes Nunez, MD, Potosi, Argentina (n)
Fernando Martin Comba, Buenos Aires, Argentina (n) The Molecular Identification of Bacteria from
Francisco Piccaluga, MD, Buenos Aires, Argentina (n) “Aseptically” Loose Implants
Abstract: Locking compression plates (LCP) uses screws that lock Naomi Kobayashi, MD, Cleveland, OH (n)
into the plate allowing multiple points of unicortical fixation. Gary W Procop, MD (n)
This feature could be an advantage to avoid damage to the Hiroshige Sakai, MD, Cleveland, OH (n)
cement mantle or a stable uncemented femoral stem in Takaaki Fujishiro, MD, PhD, Cleveland, OH (n)
periprosthetic femoral fractures. The purpose of this study is to
Lester Stuart Borden, MD, Cleveland, OH (n)
analyze clinically and radiographically a group of 14 patients
with a type B1 periprosthetic fracture treated with open reduc- Viktor Erik Krebs, MD, Rocky River, OH (n)
tion and internal fixation with LCP plates. Five fractures were Yutaka Inaba, MD, Yokohama, Japan (n)
also stabilized with additional cortical strut grafts. Eight cases Tomoyuki Saito, MD, Yokohama, Japan (n)
healed uneventfully at an average of 8 months. Three fractures Thomas W Bauer, MD, PhD, Cleveland, OH
failed through fracture of the plate within 12 months of surgery. (a – Stryker Howmedica)
A further 3 patients also failed with plate pull-out. Four of these Abstract: Several reports have documented evidence of bacteria
patients had to be reoperated. All the failures except one were associated with implants removed for clinically aseptic loos-
observed in cases where a cortical strut allograft was not utilized. ening, but more specific assays are needed to help identify
This exception was an obese patient (130 kg), who was noncom- subclinical infections. The aim of this prospective study is to use
pliant with bearing weight recommendations, presenting a frac- a molecular identification technique to test for evidence of
ture of the struts and a plate pullout at 45 days. In this series of bacteria at revision of clinically uninfected joint implants.
patients, the LCP alone was insufficient for the treatment of Ninety-two implants were retrieved from 52 cases of failed hip
periprosthetic femoral Vancouver B1 fractures. Additional and knee arthroplasties. The implants were carefully packaged in
supplementation with extramedullary fixation such as strut allo- the OR in sterile containers, then sonicated in a bath to dislodge
grafts should be routinely utilized. biofilm. Sonicate solutions were submitted prospectively for
dual real-time PCR assay combined with pyrosequencing, and
conventional culture. For culture-positive PCR-positive cases,
and for cases preoperatively suspected to be infected, microscope
slides of tissue that had been routinely submitted during surgery

364 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 365

were also reviewed, and histologic findings along with the ficity, accuracy, predictive value for positive test, and predictive
results of other laboratory tests were used to help establish a value for negative test were 0.87, 0.73, 0.83, 0.91, and 0.62,
diagnosis with respect to the presence or absence of infection. Of respectively. Previous studies have reported a sensitivity of joint
the 92 tested implants, 74 (80.4%) were clinically aseptic fail- aspirations as low as 0.5. The results of this study suggest that
ures, 14 (15.2%) were thought to be infected, and 4 (4.4%) were with the application of the specified clinical criteria, the sensi-
revised for aseptic peri-prosthetic fractures. All implants thought tivity of joint aspirations increased to 0.87. Thus, the combina-
to be aseptically loose were culture negative, but nine (12%) tion of both the specified clinical criteria and joint aspirations
were found to have bacterial DNA by PCR, and two (2.7%) were provides a predictable protocol for diagnosing infection. The
both PCR positive and showed histologic findings suggestive of investigators anticipate further analysis which will allow for
infection. All of the 10 culture-negative/PCR-positive cases were additional understanding of other factors such as concurrent
stable after revision surgery, including four that had undergone antibiotic treatment which may reduce the effectiveness of this
the second stage of a 2-stage revision for prior infection. Previous protocol. The investigators have already initiated a prospective
reports have described the use of sonication and PCR to detect study to analyze and to verify these findings.
bacteria in implant-associated biofilms. Our detection of bacte-
rial DNA with the use of a sensitive and specific molecular PAPER NO. 030
method confirms evidence of bacteria in occasional cases of clin- Does Excessive Anticoagulation Predispose the
ically aseptic loosening, but in a lower proportion than in some
previous PCR studies, suggesting enhanced specificity of this
Patient to Periprosthetic Infection?
combined method. PCR does not determine bacterial viability, Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
however, so the clinical importance of organisms detected with Elie Ghanem, MD, Philadelphia, PA (n)
this method still needs to be clarified with longer term prospec- James J Purtill, MD, Philadelphia, PA (n)
tive studies. Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
William J Hozack, MD, Philadelphia, PA (e – Stryker)
PAPER NO. 029 Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
Selection Criteria for Joint Aspirations as a Abstract: Periprosthetic infection (PPI) remains one of most
Diagnostic Test for Infection After Joint Arthroplasty challenging complications of joint replacement. A number of
Ronald Emilio Delanois, MD, Lutherville, MD (n) predisposing risk factors for PPI have been identified. The aim of
this study was to determine whether postoperative hematoma
Thorsten M Seyler, MD, Baltimore, MD (n)
formation, wound drainage, and excess anticoagulation are
Johannes F Plate, BS, Heidelberg, Germany (n)
predisposing factors for PPI. We conducted a 2 to 1 case-control
David R Marker, BS, Baltimore, MD (n) study to determine risk factors for PPI including postoperative
Michael A Mont, MD, Baltimore, MD INR. 78 cases without prior history of PPI underwent revision for
(e – Stryker Orthopaedics, Wright Medical Technology) septic failure. The control group consisted of 156 patients
Abstract: Joint aspirations are frequently used as a convenient without septic failure who were followed up for the same period.
diagnostic tool to test for septic complications of total joint The two groups were strictly matched for age, sex, surgeon, type

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

arthroplaties. Historically, the sensitivity of joint aspirations has of prosthesis, and date of implantation. The anticoagulation
been reported to be between 0.5 and 0.7. As a consequence of protocol was the same throughout the study period. Patient co-
this low test sensitivity, appropriate patient selection is generally morbidities, preoperative medications, intraoperative factors,
recommended; however, there remains controversy concerning and postoperative factors were collected and compared between
which selection criteria should be utilized to increase test sensi- the two groups using univariate and multivariate analysis.
tivity. The purpose of this study was to analyze the accuracy of Among the 78 infected cases, 26 patients had developed wound
joint aspirations performed under stringent pre-operative clin- drainage and 11 patients had incisional hematoma necessitating
ical selection criteria. For the initial clinical assessment of poten- surgical evacuation following the primary procedure. The post-
tial deep joint infections, the investigators established a system operative INR was higher among the group of patients who later
with major and minor criteria. Major criteria included: wound developed PPI. There were only two patients from the control
drainage, erythema, previous infection, ESR > 30mm/hr, and group who developed hematoma and another had post-opera-
CRP > 10mg/l. Minor criteria were fever, pain, swelling, WBC > tive wound drainage. The development of hematoma (p<0.001),
11x109 per liter, radiographic signs of prosthetic loosening, and wound drainage (p<0.001), or both (p<0.001) was significantly
the presence of one or more risk factors, such as diabetes, higher in the infected group as compared to the control group
inflammatory arthritis, sickle cell disease, HIV, and immuno- respectively. Excessive anticogulation (INR.1.5) was a significant
suppressive therapy. Patients with either 2 major and 2 minor, or predisposing factor for wound related problems and subsequent
1 major and 3 minor criteria were considered to be a candidate periprosthetic infection. The incidence of postoperative wound
with a possible joint infection and were included in this study. drainage and incisional hematoma was significantly higher in
There were 48 patients that met these criteria, all of who received patients who later became infected after their index procedure.
a joint aspiration and subsequent irrigation and debridement of The INR of those patients who later developed PPI was higher
the potentially infected prosthetic site or revision total joint than their aseptic counterparts. Postoperative hematoma forma-
arthroplasty. Corresponding cultures were collected for both the tion and wound drainage are potential risk factors for develop-
aspiration fluid and surgical site. The most common indication ment of PPI. Cautious anticoagulation to prevent hematoma
for infection was pain with all patients demonstrating reporting formation and/or wound drainage is critical to prevent PPI and
moderate to severe pain due to prosthetic complications. Other its devastating complications.
common criteria included swelling (81%), erythema (79%), and
elevated WBC (60%). The most frequent risk factors reported PAPER NO. 121
were hypertension (58%), diabetes (21%), and urinary tract WITHDRAWN
infection (13%). Using intra-operative cultures and pathologies
as the ‘gold standards’, the aspiration culture sensitivity, speci-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
365
PPSE 07:Layout 1 1/12/07 1:40 PM Page 366

PAPER NO. 122 hips). The relative risk of fracture for women versus men was
Up to 8.5 Years Follow-up of Birmingham Hip 2.75. The mean time to fracture was 75 weeks (range, 1-276
weeks). Seven (54%) fractures occurred within one year of
Resurfacing: Functional Results & Lessons Learned surgery. In women, the mean time to fracture was 95 weeks
Munawar A Hashmi, FRCS, Newcastle Upon Tyne, United (range, 1-276 weeks) and in men it was 48 weeks (range, 3-120
Kingdom (b – Smith & Nephew) weeks). The mean BMI was 28.8 (range, 12-49) with 5 (38%)
James Holland, MD, Newcastle, United Kingdom fractures occurring in patients with a BMI greater than 30.
(b – Smith & Nephew) Anatomic and/or surgical bone management problems (large
neck cysts, osteopenia, notching), surgical experience (head
Abstract: A prospective study to assess the functional outcome
seating, cement mantle), and other patient factors (BMI, female
and complications of BHR performed in a university hospital
gender) were indicated as common risk factors. The risk of
outside Birmingham. upto 8.5 years review, mean 6.5 years. A
femoral neck fracture in metal-on-metal resurfacing appears to
cohort of 100 consecutive patients (107 hips), who prospectively
be multifactorial. These findings suggest that fractures occur
underwent BHR, in an arthroplasty unit out side Birmingham.
more often in the early part of the learning curve of a surgeon.
Inclusion criteria fit and active patients. 74 male mean age 52.2
In addition, it appears that intraoperative notching, female
(median 53, range 21-68) and 26 female patients, mean age 47.8
gender, and obesity increase the risk for femoral neck fractures.
(median 51, range 27 - 64). 8 patients had bilateral procedures.
Pathology OA 84%, Perthes 5%, DDH 3% & SUFE 3%. Scoring
PAPER NO. 124
was performed by independent observer. The mean follow-up is
6.23 years, range 5 - 8.5 years. HHS: Pre op HHS was 48.65 Hip Resurfacing for Patients under 50 Years of Age
(median 48, range 10-92), improved to 98.37 (73 - 100) at first Harlan C Amstutz, MD, Los Angeles, CA
year review, and 99 (90 - 100) at final review. A statistically signif- (a, e – Wright Medical Technology, Inc., a – Los Angeles
icant improvement P = 0.001WOMAC: Pain improved from pre- Orthopaedic Hospital Foundation, William McGowan
op 18.63 to 6.48. Stiffness improved from 8.48 to 3.32 and Charitable Fund, Inc.)
Physical activity 59.27 pre-op to 26.54 post operatively.SF-36
Scott T Ball, MD, San Diego, CA (n)
Final review score, when analyzed against an age / sex match
control group of normal values using a 2 tailed ‘t’ Test, shows Michel Jean Le Duff, Glendale, CA (n)
statistically significant improvement from pre op to post op but Frederick Dorey, PhD, Los Angeles, CA (n)
no significant difference b/w final and control means. Two early Abstract: The purpose of the present study was to determine the
fractures due to AVN needing revision to THR, one following a safety and effectiveness of metal-on-metal hip resurfacing for the
fall treated conservatively and one fracture in a patient 18 treatment of young patients. From a consecutive series of over
months after radiotherapy for prostate cancer. Birmingham hip 1000 Conserve® Plus metal-on metal hybrid resurfacings, 350
resurfacing can provide consistently good results with low hips were resurfaced in 295 patients less than 50 years old.
complication rate in carefully selected group of patients. (A final Average age was 41.2 years (range, 14 to 49) with 75% male.
comparison of the leisure activities & work pattern, currently ‘Idiopathic’ OA was the dominant etiology with 50%. The
assessed, will also be presented at the meeting femoral metaphyseal stem was cemented in 105 hips and press-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

fit in the remaining 245. All acetabular components were press-

PAPER NO. 123 fit. Average follow-up was 6.4 years (range, 3 to 10.2). UCLA hip
Femoral Neck Fractures Following Metal-on-metal scores improved significantly (pain: 3.4 to 9.4; walking: 6.0 to
9.6; function: 5.6 to 9.5; activity: 4.5 to 7.6.) There were no cases
Total Hip Resurfacing of acetabular component loosening. 10 hips (2.8%) were revised
Michael A Mont, MD, Baltimore, MD for femoral aseptic loosening and 1 for femoral neck fracture. An
(a, e – Wright Medical Technology) additional 8 hips (2.3%) have radiolucencies about the femoral
Ronald Emilio Delanois, MD, Lutherville, MD (n) stem. All but 1are asymptomatic. The average surface arthroplasty
Johannes F Plate, BS, Heidelberg, Germany (n) risk index of the failed hips was higher than that of the rest of the
Thorsten M Seyler, MD, Baltimore, MD (n) cohort (4.3 compared to 2.6, p=0.0001). The 5-year survivorship
of hips with good bone quality was 97.8%. There was no femoral
Abstract: Metal-on-metal total hip resurfacing arthroplasty is
component loosening when the femoral stems were cemented
recommended for young and active patients with advanced hip
in, irrespective of bone quality. There was a significant difference
disease who are likely to outlive standard total hip arthroplasty.
in comparing the results of the first 160 hips performed with first
Femoral neck fracture as a result of stress shielding is well-docu-
generation technique and the next 190 performed with second
mented in the literature. The purpose of this study was to
generation technique. Metal-on-metal resurfacing arthroplasty of
analyze and determine the incidence of femoral neck fractures
the hip is performing extremely well at short to mid-term follow-
after metal-on-metal total hip resurfacing. Between November
up in young, active adults despite their high activity levels and
2000 and April 2006, 480 metal-on-metal total hip resurfacings
this result is consistent with previously published reports related
were performed by the senior author, and data was prospectively
to other metal-on-metal resurfacing devices. This young popula-
collected in our database. The authors reviewed operative
tion constitutes the prime indication for the procedure.
reports, patient charts, preoperative and postoperative radi-
Optimizing bone preparation and cementing the stem of the
ographs to screen for any femoral neck fracture after metal-on-
femoral component is important, in patients with risk factors.
metal total hip resurfacing. Any relevant data concerning the
occurrence of femoral neck fractures was then analyzed. In 12
patients (13 hips) fracture of the femoral neck occurred as
complication. Eleven of the first thirteen fractures occurred in
the first 50 resurfacings performed. The incidence for fracture in
these first 50 resurfacings was 22% versus 0.46% for the
remaining series (2 out of 430). The incidence for femoral neck
fractures in women was 4.4% (8 hips) and 1.6% for men (5

366 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 367

PAPER NO. 125 recorded. The 2mm notched group (mean failure 4034N) were
significantly weaker than the un-notched group (mean failure
◆A Comparison of Total Hip Resurfacing and Total 5302N) (p equals 0.017). The 5mm notched group (mean failure
Hip Replacement Patients and Outcomes 3121N) were also significantly weaker than the un-notched group
Thomas P Schmalzried, MD, Los Angeles, CA (a – Wright (p equals 0.0003) and the 2mm notched group (p equals 0.046).
Medical Technology, a, c, e – DePuy Orthopaedics) The finite element model showed a maximum superior stress of
Vincent A Fowble, MD, West Palm Beach, FL (n) 0.2MPa with no notch, 7MPa with a 2mm notch and 52MPA
Mylene A Dela Rosa, BS (n) with a 5mm notch. A superior notch of 2mm in the femoral neck
weakens the proximal femur by 24% and a 5mm notch weakens
Abstract: Internet promotions and patient postings report faster
it by 41%. The finite element analysis substantiates this showing
recovery and greater functional capacity with resurfacing than
an increasing stress within the femoral neck with increasing
total hip replacement (THR). There are few scientific compar-
notch depth. This study provides biomechanical evidence that
isons of patients with metal-metal hip resurfacing to those with
notching of the femoral neck may lead to an increased risk of
contemporary THR. Fifty consecutive metal-metal total hip
femoral neck fracture following hip resurfacing.
resurfacings in 50 patients enrolled in an FDA, IDE study were
compared with 44 consecutive total hips in 35 patients
PAPER NO. 127
implanted during the same time period by the same surgeon
and followed prospectively for 2-4 years. The hip resurfacing Femoral Component Alignment and the Risk of
patients were 62% male (p=0.03), 9 years younger (p=0.0001), Femoral Neck Fracture Following Hip Resurfacing
3.2 inches taller (p< 0.0001), with lower mean BMI (p=0.0009) Edward T Davis, FRCS, Brimingham, United Kingdom
and lower ASA grade (p=0.001). Preoperatively, resurfacing
(a, b – Smith&Nephew)
patients had a lower Harris Hip Score (HHS) (46 vs. 52;
p=0.005), reported more pain (p<0.0001), higher UCLA activity
Michael Olsen (a – Smith&Nephew)
scores (4.2 vs. 3.6, p=0.02) and better ROM (p=0.03). Surgical Zdero Radovan, PhD (a – Smith&Nephew)
time for resurfacing was 18% longer (p=0.003) but there was less James P Waddell, MD, Toronto, Canada
total blood loss (p=0.0005) and transfusions (p<0.0001). (a, e – Smith&Nephew)
Postoperatively, there was no difference in HHS (96 vs. 97). Emil H Schemitsch, MD, Toronto, Canada
Resurfacing patients had higher function (p=0.007), SF-12 phys- (a – Smith&Nephew)
ical (p=0.002) and UCLA activity (p<0.0001) scores, but a higher Abstract: We attempted to establish the effect of femoral compo-
incidence of slight or mild pain (p<0.007). There were no differ- nent alignment on the risk of femoral neck fracture following hip
ences in postoperative ROM or dislocation (1 each). The demo- resurfacing. Twenty pairs of fresh frozen cadaveric femurs were
graphics and outcomes of the 14 total hips with a large diameter obtained. Femur pairs were assigned randomly to 4 alignment
metal-metal bearing were essentially identical to those with hip groups, relative varus (10 and 20 degrees) and relative valgus (10
resurfacing. The pre-operative characteristics of the average hip and 20 degrees). Each pair contained one control specimen at
resurfacing patient are very different from those of the average neutral alignment and the other at the experimental alignment
total hip patient—and these characteristics favor a better func- value. All specimens underwent bone mineral density measure-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

tional result. On this basis, caution should be taken in ments to establish that there was no difference in bone mineral
attributing any differences in functional outcomes directly to the density between the experimental and control specimens. All
arthroplasty technology. components were cemented in place with no femoral neck
notching. The prepared femurs were placed in a position of single
PAPER NO. 126 leg stance, and tested in axial loading. A significant trend was
A Biomechanical and Finite Element Analysis of observed with 10 degrees varus alignment decreasing the ultimate
Femoral Neck Notching During Hip Resurfacing failure strength by 12 percent (mean 6009 N) and 20 degrees
valgus alignment increasing the ultimate failure strength by 32
Edward T Davis, FRCS, Brimingham, United Kingdom percent (mean 6809 N). A significant difference was found for
(a, b – Smith&Nephew) ultimate failure strength between control and experimental speci-
Michael Olsen (a – Smith&Nephew) mens within the 20 degrees valgus alignment group (p equals
Zdero Radovan, PhD (a – Smith&Nephew) 0.0273). A relative varus implant alignment when performing hip
Marcello Papini, PhD, Toronto, ON Canada resurfacing showed a trend towards decreasing the ultimate failure
(a – Smith&Nephew) strength. However, aligning the component in a 20 degree valgus
James P Waddell, MD, Toronto, ON Canada position did demonstrate a significant improvement in failure
(a, e – Smith&Nephew) strength. This study appears to demonstrate that to reduce the risk
of femoral neck fracture following hip resurfacing, an alignment
Emil H Schemitsch, MD, Toronto, ON Canada
of the femoral component of 20 degrees valgus is required.
(a – Smith&Nephew)
Abstract: It has been suggested that notching of the femoral neck
during hip resurfacing weakens the proximal femur and predis-
poses to neck fracture. We examined the effect of neck notching
during hip resurfacing on the strength of the proximal femur. 3rd
generation composite femurs were utilized. Six specimens were
prepared without a superior notch in the femoral neck, six were
prepared in an inferiorly translated position in order to cause a
2mm notch and six were prepared with a 5mm notch. The spec-
imens were then loaded to failure in the axial direction. A finite
element model was constructed using a CT model of a femur
with increasing superior notch depths and the maximum stress

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
367
PPSE 07:Layout 1 1/12/07 1:40 PM Page 368

PAPER NO. 128 prospective study of patients undergoing hip resurfacing using
Required Adjustments to Avoid Notching of the the valgus insertion technique, evaluating relative valgus angle
and complication rates. Biomechanical testing of matched fresh
Femoral Neck During Hip Resurfacing frozen cadaveric femurs implanted with valgus and neutral
Justin C Hamaker, BS, Houston, TX (n) oriented components. Tested for ultimate failure
Matthew Thompson, MS, Houston, TX (n) load.Prospective evaluation of 188 patients undergoing hip
Philip C Noble, PhD, Houston, TX (n) resurfacing looking at valgus angle, notching, and complications
Justin Noel, Houston, TX (n) rates. The ultimate failure load is significantly increased for the
Justin Peter Cobb, MD, London, United Kingdom (n) valgus-oriented components: 9091 N vs 7257 N (p value = 0.03).
The average relative valgus angle was 16.4 degrees. Ultimate
Abstract: Despite recent improvement in the outcome of hip
failure load was inversely related to bone mineral density and
resurfacing, femoral neck fracture remains a major concern. To
directly related to relative valgus angle. An average 12.9 degrees
lessen this risk, notching of the femoral neck must be strictly
relative valgus measured for the clinical group. Complications: 3
avoided. This often necessitates anterior/superior displacement
deep infections and 3 asymptomatic heterotopic ossification. No
and/or upsizing of the implant. In this study, we analyze what
periprosthetic fractures. Valgus-oriented femoral components
amounts of head shifting and upsizing are necessary to resurface
decrease the risk of periprosthetic femoral neck fracture.
a hip without notching. Computer models of a standardized
Osteoporotic femurs benefited more from the valgus orientation
design of resurfacing arthroplasty were implanted in 3D models
and the benefit was greater the greater the degree of valgus.
of 13 femora (average NSA=126º±3.3º). In each case, the femoral
component was oriented in a fixed valgus angle of 140° angle, PAPER NO. 130
with its head size and head center exactly matching that of the
original femur. The implant was then repositioned and upsized Establishing a Learning Curve for Hip Resurfacing
until notching was avoided. This process was then repeated with Diane L Back, FRCS Ed Orth, Chesham, United Kingdom
the implant oriented parallel to, and 5° more valgus than, the (n)
original neck axis. The change in final head center location and the Jay D Smith, MRCS (n)
average depth of required subchondral acetabular bone reaming Rodney E Dalziel, MD, Melbourne, Australia (a – Osteoz)
were calculated. Regardless of repositioning, a femoral compo- David Alexander Young, MD, Windsor, Australia (*)
nent equal to the original subchondral head size could rarely be
John Skinner, FRCS, London, United Kingdom (a – Osteoz)
implanted without notching (0% in 140°; 15% in NSA and
NSA+5°). Upsizing of the implant by 2mm reduced the incidence Andrew John Shimmin, MD, Windsor, Australia (a – Osteoz)
of notching to 0% for the neck axis, 8% for the NSA+5°, and 40% Abstract: With shortened training programmes advocated, we
at 140°. However, this necessitated displacement of the head have established a learning curve for hip resurfacing in experi-
center by an average of 0.90mm superiorly, 1.30mm anteriorly, enced consultants. We prospectively planned the placement of a
and 1.77mm laterally. To accommodate the combination of repo- hip resurfaicng prosthesis. Using CUSUM analysis we estab-
sitioning and increased head size, the reamed diameter of acetab- lished how long it took for consistent placement of the pros-
ulum also increased by an average of 2.72mm. Resurfacing of hips thesis to take place. 4 experienced surgeons learning the hip
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

can be successfully performed when the implant is placed at resurfacing procedure were included. Thus negating the need to
moderately valgus angles. However, it does require significant learn basic surgical skills. Evaluating the first 100 cases of each,
increases in head size, as well as shifts in the head center anteriorly showed that the learning curve between planned and achieved
and laterally to avoid notching of the femoral neck. The end result implant position was in the order of 50 cases. The learning curve
is a compromise of the original femoral offset and loss of bone was longer than estimated and has huge implications, with
stock on the acetabular side. shortened training programmes and less operativ exposure
ebing advocated throughout the world.
PAPER NO. 129
PAPER NO. 131
◆Periprosthetic Fracture in Hip Resurfacing: Valgus
Precision of Total Hip Replacement Using
vs Neutral: A Biomechanical & Clinical Analysis
Imageless Computer Navigation
Corey Richards, MD, Montreal, QC Canada (n)
Pierre Naverre, BA (n) Aamer Malik, MD, Inglewood, CA (n)
Demetri Giannitsios, MEng, , (n) Lawrence D Dorr, MD, Inglewood, CA (a, c – Zimmer)
Olga Huk, MD, Westmount, Canada (n) Zhinian Wan, MD, Inglewood, CA (n)
David Zukor, MD, Montreal, Canada (n) Leigh E Sirianni, OPA-C, Inglewood, CA (n)
Thomas Steffen, MD, Montreal, Canada (n) Myriam Boutary, Burbank, CA (n)
John Antoniou, MD, Montreal, Canada (n) Abstract: Introduction: Computer navigation provides high tech-
nology instrumentation for accuracy of THR. The purpose of this
Abstract: Periprosthetic femoral neck fractures following hip
study was to determine the accuracy and precision of imageless
resurfacing is a significant post-operative complication.
computer navigation for acetabular reconstruction and compare
Retrospective studies have associated some of these fractures
the precision of the computer to that of the surgeon. Methods:
with a relative varus position of the femoral component. This
60 patients with 66 hips were operated using computer naviga-
has lead to the insertion of femoral implants in a slight absolute
tion. Precision and bias were measured through 14 postopera-
valgus orientation (140 degrees). The purpose of this investiga-
tive CT scans; precision was measured for all 66 postoperative
tion was three-fold: (1) to validate a valgus insertion technique
radiographs. The surgeon’s blinded estimate of inclination and
providing maximum valgus angle while avoiding notching; (2)
anteversion for each hip was compared to computer navigation
to determine, via biomechanical testing of matched fresh frozen
measurements for surgical precision. Intraoperative data with
cadaveric femurs, if valgus-oriented femoral components are
computer navigation was adjusted for pelvic tilt and measured
more resistant to femoral neck fractures; (3) to complete a
for inclination, anteversion, and change of center of rotation in

368 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 369

3 planes-mediolateral, cephalocaudad, and anteroposterior. PAPER NO. 133

Results: The precision of the computer navigation for inclination A Prospective Randomized Trial Shows 2-Incision
was 3.6 degrees with a bias of 0.64 and for anteversion was 4.4
degrees with a bias of 0.5. The precision measured against post- THAs do not Recover Quicker than Mini-Posterior THAs
operative x-rays for inclination was 9.1 degrees with a bias of 3.9 Mark W Pagnano, MD, Rochester, MN (c – Zimmer)
degrees and 11.5 degrees for anteversion with a bias is 2.1 James Leone, MD, Ancaster, ON Canada (c – Zimmer)
degrees. Experienced surgeons precision was 11.4° for inclina- Robert Michael Meneghini, MD, Indianapolis, IN
tion and 12.3° for anteversion, while less experienced surgeons (c – Zimmer)
precision was 14.6 degrees for inclination and 13.6 degrees for Emily J Berg, AA (c – Zimmer)
anteversion. Conclusion: Computer navigation is precise to
Abstract: Proponents of 2-incision total hip arthroplasty (THA)
within 4 degrees. Surgeons mean estimates that occur with
have claimed that the recovery after that procedure is dramati-
mechanical guides, judgment and experience are within a mean
cally quicker than that after other methods of performing THA.
of 12 degrees of the computer, but percentage of outliers beyond
To date however there is no data that directly compares 2-inci-
5 degrees for experienced surgeons is about 30% while for less
sion THA to another method of THA in similar groups of
experienced surgeons around 50%. The computer will eliminate
patients using the same advanced anesthetic and rehabilitation
outliers which will improve stability, impingement, and wear.
protocol. We conducted a prospective randomized clinical trial
PAPER NO. 132 comparing two-incision THA (Mears/Berger technique) versus
mini-posterior THA. This study was designed to ensure adequate
◆Does the Use of a Navigation System Improve statistical power to detect even small (5 day) differences in the
Precision in Surface Replacement of the Hip? measures of early functional recovery. A computerized random-
Lars Perlick, MD (b – DePuy, Brainlab) ization process dynamically balanced the groups based on age,
Holger Bathis, MD, Cologne, Germany (b – DePuy, Brainlab) gender, race, and body mass index. Early function was deter-
mined by a milestone diary. SF-12 scores were done preopera-
Thomas Kalteis, MD, Bad Abbach, Germany
tively and at 2 month and 1 year followup. All THAs were done
(b – DePuy, Brainlab) by a surgeon experienced in both techniques. 72 patients with a
Johannes Beckmann, MD (b – DePuy, Brainlab) mean age of 66 (40-85) were enrolled and this included 20
Christian Luring, MD (b – DePuy, Brainlab) males and 16 females in each group. The mean BMI was 29.5
Abstract: During the past decade, there has been a resurgence of (21-46). The mean time to discontinue ambulatory aids, to
interest in hip resurfacing as a mode of treatment for the younger return to normal daily activities, and to climb stairs was shorter
patient with hip disease since major disadvantages of previous for the mini-posterior patients than for the two-incision patients.
resurfacing systems have been overcome. The purpose of the The mean time to discontinue narcotics was shorter for the two-
presented study was to clarify if an imageless navigation system incision patients. This prospective randomized trial dispels the
will allow precise placement of the femoral component Between notion that the two-incision THA technique dramatically
September 2004 and May 2006, 50 metal-on-metal surface improves short term recovery after THA, instead it was the mini-
arthroplasties each were performed either using an imageless posterior patients who had the quicker recovery in most cate-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

navigation system or the conventional technique. The inclina- gories measured.
tion and the axial alignment of the femoral component were
determined by two independend examiners and compared to PAPER NO. 134
the values presented by the navigation system. In the preopera- No Benefit of the Two-Incision THA over Mini-
tive x-rays a mean CCD-Angle of 129.2 degrees (Control group:
127.5°) was measured. The mean femoral shaft angle was 137.5
Posterior THA: A Comprehensive Gait Analysis Study
degrees (Control group 133°) postoperatively with a mean devi- Mark W Pagnano, MD, Rochester, MN (c – Zimmer)
ation of 2.1 degrees compared to the values shown by the Robert Michael Meneghini, MD, Indianapolis, IN
system. In the computer assisted group the mean deviation from (c – Zimmer)
the ideal placement in the axial plane was 2.9 degrees compared Kenton R Kaufman, PhD, Rochester, MN (c – Zimmer)
to 4.8° when using the conventional technique. The use of a Krista Coleman-Wood, PhD (c – Zimmer)
navigation system was associated with only an average time loss Emily J Berg, AA (c – Zimmer)
of 7 minutes for surface data acquisition und mounting of the
Abstract: 2-incision total hip arthroplasty (THA) advocates have
reference base. The computer assisted technique appears to be
touted that the recovery is dramatically quicker than that after
helpful to avoid notching during the femoral bone preparation
other methods of performing THA. Comprehensive gait analysis
and improve implant positioning which might improve dura-
and strength testing that directly compares the two-incision tech-
bility.
nique versus another method of THA has not been done in
similar groups of patients. We conducted a prospective random-
ized clinical trial comparing two-incision THA (fluoroscopically
assisted Mears/Berger technique) versus mini-posterior THA. 10
patients in each group underwent comprehensive preoperative
and postoperative (8 week and 1 year) gait analysis and strength
testing. Gait parameters including step length, velocity, cadence,
single-leg stance time, stride length, and step width were
recorded when both walking on level ground and when
ascending stair. Strength testing was done with a Biodex
machine. A computerized randomization program ensured that
both groups were dynamically balanced according to age, gender
and body mass index. The mean age of the patients was 66. Both

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
369
PPSE 07:Layout 1 1/12/07 1:40 PM Page 370

groups showed marked improvements in gait velocity, stride was no difference in the Trendelenburg test between the two
length, and step width at the 8 week postoperative testing with groups (p=0.82). We concluded that the abductor muscle
strong trends for the mini-posterior group to be better. The strength after total hip arthroplasty had not been detected
single-leg stance time (a measure of the degree of antalgia) was between the surgical approaches.
markedly better (p=0.023) in the mini-posterior group. This
comprehensive gait analysis and strength testing study refutes PAPER NO. 152
the contention that the two-incision THA technique dramati- Gait Analysis of MIS THR
cally improves short term recovery after THA. Mini-posterior
Leigh E Sirianni, OPA-C, Inglewood, CA (a – Zimmer)
hips performed significantly better as measured by single-leg
stance time at the 8 week followup visit.
Lawrence D Dorr, MD, Inglewood, CA (a – Zimmer)
Andrew Yun, MD, Marina Del Rey, CA (a – Zimmer)
PAPER NO. 135 William T Long, MD, Inglewood, CA (a – Zimmer)
Early Outcomes Following MIS THA Using Two- Samuel R Ward, PhD, Los Angeles, CA (a – Zimmer)
Myriam Boutary, Burbank, CA (a – Zimmer)
Incision Versus a Mini-Posterior Approach
Mara Cardon, BS (a – Zimmer)
Aree Tanavalee, MD, Bangkok, Thailand (n)
Abstract: Introduction: Currently there is debate as to whether
Sarayut Jaruwannapong, MD (n) small incision THR surgery is associated with accelerated postop-
Abstract: To compare early outcomes of consecutive series of erative recovery. In this study, we sought to find objective data
MIS THA using 2-incision approach versus mini-posterior supporting the expectation that posterior MIS THR patients
approach. A consecutive series of 35 patients (40 hips) with 2- recover function more quickly within the first six weeks of surgery
incision THA and a consecutive series of 35 patients (36 hips) Methods: 48 patients underwent instrumented gait analysis
with mini-posterior THA performed in the same period were preoperatively and at 6 weeks postoperatively. There were three
evaluated. Both groups had the same selection criteria. The groups matched by age and BMI and preoperative gait character-
mean follow-up was 25.2 months. The 2-incision group had istics with one group having posterior MIS, one anterior MIS, and
significantly earlier ambulation, driving ability and return to one group with traditional posterior THR. Linear regression was
work. However, it had significantly more operative time, blood used to determine the association between preoperative function
loss, blood transfusion and complications. There was no statis- and postoperative functional recovery. Gait velocity, cadence,
tical difference of the implant position between groups. stride length, and single limb support time were then compared
Although MIS 2-incison THA provided faster early ambulation between groups using a repeated measure analysis of covariance.
than that of mini-posterior THA, surgeons have to concern Results: Preoperative gait velocity was positively correlated with
some disadvantages of this technique. gait velocity at six weeks (r2 = 0.100 p = 0.042) and therefore was
used as a covariant. Across all groups the average gait velocity
PAPER NO. 151 increased 10% at 6 weeks compared to preoperative values (65.0
Hip Abductor Strength Following THA Using Direct +/- 2.47 m/min vs. 72.9 +/- 2.74 m/min, p = 0.035). At six weeks,
Lateral vs Posterior Approach there were no significant differences between groups in terms of
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

velocity (p = 0.229) cadence (p = 0.518), stride length (p =

Takahiko Kiyama, MD, Fukuoka, Japan (n) 0.275), or single limb support time (p = 0.570). Discussion and
Masatoshi Naito, MD, Fukuoka, Japan (n) conclusion: These data indicate that patients having THR with
Yuichiro Akiyoshi, MD, Fukuoka, Japan (n) any of these surgical approaches recover gait function to near
Hiroshi Shitama, MD, Fukuoka, Japan (n) normal levels within 6 weeks postoperatively. The exceptionally
Takafumi Kumano, MD, Fukuoka, Japan (n) fast recovery times observed do not differ between the mini inci-
Tsuyoshi Shinoda, MD, Fukuoka, Japan (n) sion techniques and the standard posterior approach. This study
Akira Maeyama, MD, Fukuoka, Japan (n) does support the use of immediate full weight bearing recovery
Takeshi Teratani, MD, Fukuoka, Japan (n) with use of a cane in noncemented arthroplasty.
Akinori Takeyama, MD (n) PAPER NO. 153
Abstract: Several approaches to hip arthroplasty have been devel-
oped, but there is no consensus regarding the best approach. The Fast-Track THR: Two Day Length of Stay Protocol
purpose of this study was to compare the abductor muscle for Total Hip Replacement
strength between direct lateral and posterior surgical approach. Lawrence Gulotta, MD, New York, NY (n)
We evaluated 114 limbs in 57 patients with unilateral primary Kristin L Foote, New York, NY (n)
total hip arthroplasty and nondiseased contralateral hip at a
Thomas P Sculco, MD, New York, NY (n)
minimum postoperative time of 2 years. Thirty six patients
Stephen Lyman, PhD, New York, NY (n)
(average age: 58 years) with posterior approach (group P) and 21
patients (average age: 57 years) with direct lateral approach Bryan J. Nestor, MD, New York, NY (n)
(group D) participated in this study. Their maximal isometric Abstract: With increasing pressures to reduce length of stay, objec-
strengths were evaluated at latest follow-up visit using a Microfet tive data defining the limits of hospitalization and factors that
hand held dynamometer. The ratio of normalized strength of influence length of stay will be important. This study evaluates the
the reconstructed side to that of the nonoperated side was calcu- feasibility and safety of a protocol for two day length of stay
lated (strength ratio). Each patient underwent clinical evaluation following total hip replacement. Modifications to an existing clin-
according to the delayed Trendelenburg test. Average the ical pathway for THR consisted of ambulation within six hours of
strength ratio of posterior and direct lateral approaches were surgery and modification of postoperative pain management.
84.4% and 86.4%. In the group P, 7 of 36 patients had a posi- One hundred forty-seven patients (96 male/51 female) met the
tive Trendelenburg sign, and 5 of 21 in the group D. There was inclusion criteria: unilateral, uncomplicated hip arthritis in
no apparent difference on the abductor muscle strength between patients 70 years or younger with ASA Class II rating or less, no
posterior and direct lateral approaches (p = 0.93). Similarly there significant co-morbidities, absence of psychosocial/environ-

370 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 371

mental/social support issues, and preoperative ambulatory status and damage to the abductor repair. 309 patients post nonce-
without assistive devices or > 1500 feet with cane. Fifty-seven mented taper stem THA(Summit”/Pinnacle”) via direct lateral
percent of patients enrolled in the Fast Track Protocol were approach(with bone flake) were divided into two groups by
discharged within 2 days. Forty-six of sixty-three remaining rehabilitation protocols. Protocol 1(n-163): 20% weight-bearing
patients went home on day 3. Postoperative complaints of dizzi- for 6wks, then full weight-bearing. Protocol 2(n=146): imme-
ness, nausea, and antiemetic use on postoperative day one, and diate full weight-bearing. Averages(protocol-1/protocol-
pain on postoperative days one and two were statistically signifi- 2):(90F,73M)/(69 F, 77M); age:60yrs(17-87)/64yrs(29-89); BMI:
cant factors that differed between the successful and unsuccessful 30(24-53)/28.6(16- 41.8). Harris Hip scores(HHS) were calcu-
groups. There were no statistically significant differences in age, lated at 1 year. Radiographic evaluation for trochanteric bone
BMI, primary diagnosis, cemented versus uncemented, study flake union and Engh score was performed at 6 weeks and 1 year.
participation in first or second half, narcotic use, and preoperative Mean post-operative HHS(protocol-1/protocol-2):
Harris Hip Scores. There were six readmissions after discharge: 88/86(p=.118), at avg. of 1 yr follow-up. Average Engh’s radi-
three for dislocation, two for revision THA, and one for blood ographic score was significantly higher for protocol 2(6.57),
transfusion. Discharge within two days of surgery is both feasible compared to protocol 1(4.92)(p= 0.0023). No significant differ-
and safe for a select group of young, healthy patients undergoing ence in incidence of Heterotopic ossification(HO):
uncomplicated unilateral total hip replacement. 72.4%/68.5%(p= 0.5314). Incidence of bony flake radiolucency
was equal for both groups(49.7%/50%) Significant increase in
PAPER NO. 154 implant subsidence at the end of one year in protocol
A Clinical Comparative Study of Direct Anterior 1(p=0.0112). Trochanteric bursitis was evenly distributed in both
groups(8% & 8.5%), Time to clinical discharge for annual
Approach and Mini-Posterior Approach in MIS-THA follow up: 3.6months/2.8months (p=.045). No revision proce-
Katsuya Nakata, MD, Amagasaki, Japan (n) dures. More aggressive post-operative rehabilitation protocol
Masataka Nishikawa, MD, Toyonaka, Osaka, Japan (n) utilizing immediate full-weight bearing proved to have no signif-
Koji Yamamoto, MD, Osaka, Japan (n) icant complications at short-term follow-up, while decreasing
Shigeaki Hirota, MD, Toyonaka, Osaka, Japan (n) the time to clinical discharge by 3.5 weeks(22%). Radiographic
Abstract: The purpose of the present study is to clarify the effec- scores were better along with decreased incidence of femoral
tiveness of muscle preservative MIS-THA using direct anterior stem subsidence for the early weight-bearing group.
approach by comparing with muscle sectioned MIS-THA using
mini-posterior approach. We compared fifty MIS-THAs by using PAPER NO. 156
direct anterior approach with supine position (group A) with fifty Jump Distance as a Function of Acetabular
MIS-THAs by using mini-posterior approach with side-up posi- Abduction Angle and Femoral Head Size
tion (group P). The average age at operation was 57 years. The
Thomas J Blumenfeld, MD, Sacramento, CA (e – DePuy)
average BMI was 22.4 kg/m2. The average follow-up period was 33
months. Preoperative functional hip score was 43 points. Primary Abstract: Increasing the femoral head diameter in revision total
diagnosis was secondary osteoarthritis due to hip dysplasia in 82 hip arthroplasty to solve the problem of recurrent dislocations is
an attactive option. The true gain in the “jump distance” or the

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

percent of cases. There were no significant differences in preoper-
ative patient profiles, postoperative pain management and reha- lateral translation required before the femoral head dislocates
bilitation protocol between the two groups. We evaluated from the acetabulum is dependent on the acetabular abduction
operative invasion, implant alignment and functional recovery. angle. Knowledge of the true gain in millimeters of lateral trans-
There were no significant differences between group A and P in lation may be important in the decision making process prior to
operation time (108 versus 118 minutes), blood loss volume (531 revison surgery. Femoral head diameters of 28, 32, 36, 40, 44
versus 392 ml) and implant alignment. All cups in group A and and 48 mm were examined. The acetabular abduction angle was
eighty-three percent of cups in group P were implanted within safe varied from 20 to 80 degrees in 10 degree increments. The true
zone of Lewinnek. In group A, required time up to walking by amount of femoral head coverage for each abduction angle was
single cane, standing by operated single leg and negative graphed. The net gain in lateral translation for a fixed acetabular
Tredelenburg sign were significantly shortened. Postoperative abuction angle varies as the cosine of the abduction angle times
dislocation rate (0 versus 2 percent) and hospital stay were the femoral head radius, not the diameter. At an abduction angle
reduced in group A. Joint function was faster recovered and of 45 degrees the net change in lateral translation for a 4 mm
hospital stay was more shortened in muscle preservative MIS- increase in head diameter is 1.4 mm. As the abduction angle
THA. Less change of pelvic angle during operation can be recog- increases, the net change decreases. Although the use of large
nized and reliable axis for implantation can be available in muscle femoral heads to solve dislocation in total hip arthroplasty is
preservative MIS-THA with supine position, which is followed by appealing, the reported literature still suggests a failure rate of 25
accurate cup positioning and reduced dislocation rate. percent in most series. This failure rate equals the reported rate
with the use of more standard (28 and 32 mm) femoral head
PAPER NO. 155 sizes. If acetabular component retention is planned in revision
surgery, the true gain in lateral translation, particularly as the
Immediate Full-Weight Bearing Rehabilitation abduction angle increases, is minimal despite the use of large
Protocol for Total Hip Arthroplasty Patients femoral heads. Knowledge of the true gain in lateral translation
Thomas L Bernasek, MD, Temple Terrace, FL (a, c – DePuy distance may be important in planning the revision strategy.
Orthopaedics Inc, a Johnson & Johnson Company)
George John Haidukewych, MD, Temple Terrace, FL (n)
Jennifer L Stahl, BS (n)
Abstract: This study evaluates functional and radiographic effects
of immediate full weight bearing THA performed with nonce-
mented tapered implants, against the risks of early loosening

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
371
PPSE 07:Layout 1 1/12/07 1:40 PM Page 372

PAPER NO. 157 spherical cups averaged 213, 528, 639, and 734N for interference
Use of the Acetabular Labrum and Transverse levels of 0.25, 0.50, 0.75, and 1.00mm, respectively. The fixation
strengths at each of the interference intervals were 29%, 72%,
Acetabular Ligament to Control Cup Placement 87%, and 100%, in terms of the percentage of fixation strength
During THA of each interference level as compared to the 1.0mm oversized
Raghuram Thonse, MS, Belfast, United Kingdom cup. Fixation strength, or stability, of acetabular cups is strongly
dependent on the level of interference. An interference of 1mm
(a – Depuy)
or greater is critical for the stability of press-fit cups. Over-
Vincent Kent, MD, Marina Del Rey, CA (n) reaming or improper reaming of the acetabulum may result in
Pooler H A Archbold, MB Ba, Lisburn, United Kingdom (n) an interference of less than 1mm, creating poor fixation and
Jim McConway, MB (n) increasing the likelihood for cup motion.
Dennis Molloy, MRCS, Belfast, Antrim Ireland (n)
David Beverland, MD, Belfast, Ireland (a – Depuy) PAPER NO. 159
Abstract: Computer-assisted THA systems and conventional cup Differences in Outcomes of Obese Women and Men
alignment guides rely on the anterior pelvic plane(APP) as a Undergoing Primary Total Hip Arthroplasty
reference frame to define a predetermined goal for cup orienta-
tion. However due to errors introduced from the inaccurate local- Anne Lubbeke-Wolff, MD, MS, Onex/Geneva, Switzerland
isation of the APP and the wide variation in the natural (n)
orientation of the acetabulum mal-alignment of the cup can Richard E Stern, MD, Eysins, Switzerland (n)
occur. There is therefore a clear need to develop a method for Guido Garavaglia, MD (n)
establishing cup orientation that is patient specific and inde- Line Zurcher, MD, Onex/Geneva, Switzerland (n)
pendent of the APP.We believe that the transverse acetabular liga- Pierre J Hoffmeyer, MD, Geneve 4, Switzerland (n)
ment (TAL) in combination with the acetabular labrum can be Abstract: Our objective was to evaluate the effect of obesity on the
used to do this. Use of this technique in a cohort of 1000 cases incidence of main complications (infection, dislocation and revi-
resulted in a dislocation rate of 0.6% (Minimum follow-up 1yr sion), functional outcome and patient satisfaction five years after
Range 12-42 months). In this further series of 500 consecutive primary total hip arthroplasty (THA), and to determine whether
primary hip replacements we determine the radiographic orien- results differ between obese women and men. Hospital-based
tation of the cups placed using this technique and discuss their prospective cohort study including primary THA (n=2495 hips)
positioning with respect to the suggested ‘safe zones’ for cup performed between 1996 and 2005. We used rates and rate ratios
placement. The positions of the acetabular cups were calculated to compare the incidence of main complications in obese and
from standardised radiographs, using the method described by non-obese patients, and stratified for gender. Functional outcome
Widmer. Average radiographic inclination was 45.6° (Range 36- was measured using Harris Hip Score and WOMAC. The adjusted
61° SD 5.2°) and average radiographic anteversion was incidence rate ratio for infection (obese versus non-obese) was 4.4
15.8°(Range 4-34° SD 6.0°). Residual labrum was present in (95% CI 1.8; 10.8). Obesity substantially increased the infection
94% of cases while the TAL was present in all cases. The labrum rate in women (incidence rate ratio comparing obese to non-
and TAL are dependable landmarks that not only allow delivery
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

obese women 16.1, 95% CI 3.4; 75.7), whereas obesity appeared

of the cup to within the ‘safe-zone’ but allow placement of the to have no effect in men (incidence rate ratio 1.0, 95% CI 0.2;
cup in a patient specific region within this zone. 5.3). The adjusted incidence rate ratio for dislocation (obese
versus non-obese) was 2.4 (95% CI 1.4; 4.2) with a higher rate
PAPER NO. 158 increase in obese women. Eight hundred seventeen patients had a
Changes in the Amount of Oversizing of a 5 year clinical follow-up visit. Functional outcome and satisfaction
were slightly lower in obese women partly due to higher compli-
Hemispherical Acetabular Cup Can Affect Fixation cation rates. No difference was seen in men. Primary total hip
Strength arthroplasty is a successful intervention in obese patients, but
Jerry W Alexander, BS, Houston, TX (*) physicians and patients must be aware of the increased risk of
Matthew Thompson, MS, Houston, TX (*) infection and dislocation, particularly in women.
Molly M Usrey, BS, Houston, TX (*)
PAPER NO. 160
Philip C Noble, PhD, Houston, TX (*)
Abstract: Stable long-term fixation of cementless acetabular cups Cobalt Chromium vs. Titanium in Identical Flat,
critically depends on the degree of immobilization of the shell- Tapered Wedge Design Cementless Femoral Stem
bone interface achieved at surgery. With press-fit cups, this initial Outcomes
stability is achieved by selecting a cup that is slightly larger than
the reamed acetabulum. The purpose of this study was to John F Tilzey, MD, Beverly, MA (a – Depuy)
examine the effect of modifying interference by comparing Richard Iorio, MD, Burlington, MA (a – Depuy)
acetabular cup fixation of four different reamed cavity sizes. Flats Lawrence Specht, MD, Burlington, MA (a – Depuy)
A surrogate model of the acetabulum and periacetabular bone- William L Healy, MD, Burlington, MA (a, b, e – Depuy)
stock was developed and validated for evaluation of cup fixation. Abstract: A prospective randomized study evaluating clinical
Six surrogates were reamed to each of the final diameters: 54.00, results, patient outcome and thigh pain prevalence related to flat
54.25, 54.50, and 54.75mm. Plasma-sprayed, hemispherical, tapered wedge cementless femoral stem made of cobalt
titanium shells of 55mm in diameter were implanted in the chromium or titanium alloy. From April 1999 to April 2004, 423
surrogate acetabula with a 4000N load. A cyclic incremental primary THA operations were performed in 386 patients: 217
load was applied to the rim of each shell until the peak load cobalt chromium stems; 206 titanium stems. Pre-operative Harris
exceeded 1000N or interface motion was greater than 200 Hip score was 49.2 for the cobalt chrome cohort and 50.8 for the
microns. Loads to cause 200microns of motion were recorded. titanium cohort. Average follow-up was 3.3 years (2.0 to 6.7
The fixation strength at 200microns of motion of the hemi- years). Clinical results and patient outcome was similar for both

372 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 373

femoral stems. There was no difference in the incidence of thigh WOMAC. Radiographic analysis was performed to assess differ-
pain associated with femoral stem size (p=0.435). There was not ences using the various components. DXA was used to deter-
a statistically significant difference in clinically relevant thigh pain mine changes in peri-prosthetic BMD. There were differences
when comparing cobalt chromium or titanium stems nor with between groups for the HHS, SF-36 and WOMAC scores. The
relation to proximal femoral morphology. There were no re-oper- EPOCH components showed better results for pain, stiffness
ations for thigh pain in this series. There was one cobalt chrome and function. Radiographs revealed no difference in the inci-
stem revision for subsidence 99.8% survivorship A flat tapered dence of assessment criteria. DXA results showed increases in
wedge femoral stem made of cobalt chromium or titanium was BMD for the EPOCH components, but this may be due to
associated with outstanding clinical results and patient outcome patient positioning and sampling errors. The results from this
following THA. Larger femoral stems and cylindrical proximal trial showed that a composite femoral component for primary
femoral morphology was not associated with an increased inci- THA can achieve results equal to standard alloy components of
dence of thigh pain. varying design. Based on these early results, the EPOCH femoral
components for primary THA are justified for continuance of
PAPER NO. 161 further prospective study.
Total Hip Arthroplasty Using a Tapered Femoral
PAPER NO. 163
Component: A 20 Year Average Follow-up Study
Jeffrey McLaughlin, MD, Oshkosh, WI (a, c – Biomet)
Pulmonary Embolism Was More Frequent in
Kyla R Lee, MD, Lacrosse, WI (a, c – Biomet) Cemented THA than Cementless THA and TKA
Abstract: This study evaluated the clinical results, incidence of Koh Shimizu, MD, Chiba, Japan (n)
osteolysis, and efficacy of fixation using an uncemented femoral Sara Shimizu, MD, Chiba, Japan (n)
component. At an average follow-up of 20 years, no femoral Masayasu Yamagata, MD, Ichihara City, Chiba, Japan (n)
component required revision for aseptic loosening and only one Masahiko Saito, MD, Yotsukaido City, Chiba, Japan (n)
was loose by radiographic criteria. Osteolysis occurred in seven Abstract: Highly pressurized cementing technique has been
percent. 145 consecutive uncemented total hip arthroplasties in recommended to avoid loosening of the femoral component in
138 patients were performed by a single surgeon between 1983 THA. However, it may have the risk of decreasing the pulmonary
and 1985 using the Taperloc femoral component. The outcome circulation due to fat or bone marrow embolism. The purpose of
of every hip was determined. Eighty patients (80 hips) died prior this study was to determine the decrease ratio after cemented
to the 18-year minimum follow-up period. Of these, 75 femoral THA, compared with cementless THA, cemented TKA, and
components (94 percent) were in place. Therefore, 65 hips in 58 cementless TKA. Furthermore, multivariate analysis identified
patients were reviewed at a mean follow-up of 20 years (range risk factors including age, gender, BMI, and laboratory data.
18-22 years). Detailed follow-up was obtained on every living Preoperative and 42-hour postoperative pulmonary scintigraphy
patient. All 145 hips were included in the survivorship analysis. (99mTc-MAA) were performed prospectively in 150 patients.
No femoral component required revision for aseptic loosening. Pulmonary circulation was qualitatively evaluated by using
Three (4 percent) were reivsed for late sepsis. Five (8 percent) SPECT (single photon emission CT), and the decrease ratio of
well-fixed components were revised during acetabular revision.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

pulmonary circulation was calculated in 25 cemented THA, 50
Of those not requiring revision, 96 percent demonstrated fixa- cementless THA, 25 cemented TKA, and 50 cementless TKA.
tion by bone ingrowth, three percent stable fibrous ingrowth Multivariate analysis identified risk factors including age, gender,
and only one was loose by radiographic criteria. Lysis occurred BMI, laboratory data. The average decrease ratio of pulmonary
in seven percent. Survivorship analysis estimated a 91 percent circulation was 15% in cemented THA, 7% in cementless THA,
survival for the femoral component at 22 years (95 percent 6% in cemented TKA, and 7% in cementless TKA, and the
confidence interval 0.84 to 0.97). The one percent incidence of highest decrease ratio (39 %) was observed in a patient with
aseptic loosening and seven percent incidence of osteolysis at 20 cemented THA. There was significant coleration between the
years are excellent. These results demonstrate that the Taperloc decrease ratio of pulmonary circulation and decrease of Pao2.
femoral component can provide stable fixation out to 22 years. Among the risk factors, age, total cholesterol, and BMI were stat-
ically correlated with the decrease ratio of pulmonary circula-
PAPER NO. 162 tion. In the elder patients with high total cholesterol or high
Composite Femoral Component in THA: BMI, cemented THA should not be recommended, considering
Prospective, Randomized, Clinical, Radiographic the decrease ratio of pulmonary circulation.
and DXA Comparison PAPER NO. 164
Russell Glen Cohen, MD, Tucson, AZ (a, e – Zimmer) Thigh Pain in Primary Hip Arthroplasty
Jay A Katz, MD, Tucson, AZ (a, e – Zimmer)
Carlos J Lavernia, MD, Coral Gables, FL (a – Zimmer,
Scott V Slagis, MD, Tucson, AZ (a, e – Zimmer)
Medtronic, e – Zimmer, Orthosoft, d – Zimmer)
John A Maltry, MD, Tucson, AZ (a, e – Zimmer)
Victor Hugo Hernandez, Miami, FL (n)
Lawrence R Housman, MD, Tucson, AZ (a – Zimmer)
Michele R D’Apuzzo, MD, Miami, FL (n)
Nebojsa V Skrepnik, MD, Tucson, AZ (a – Zimmer)
Juan Felix Astoul Bonorino, MD, Buenos Aires, Argentina (n)
Abstract: A multi-surgeon, prospective, randomized controlled
David Lee, PhD, Miami, FL (n)
trial to compare clinical, radiographic and DXA results between
a composite component and a series of Ti alloy components was Abstract: Multiple factors have been associated with thigh pain
conducted. The EPOCH components were studied in conjunc- (TP) after THA. Offset and bone rigidity have been discussed as
tion with the VerSys Fiber Metal Taper, Fiber Metal Midcoat, possible etiological factors. Our objective was to assess the effect
Beaded Fullcoat components. All 227 patients were randomized of offset, bone quality and bone stiffness in the development of
into one of five groups and followed prospectively for two years. TP after primary THA. 101 patients that underwent primary THA
All patients were assessed using the Harris Hip Score, SF-36 and were studied. A pain drawing of the lower extremities was used

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
373
PPSE 07:Layout 1 1/12/07 1:40 PM Page 374

to assess the presence of TP pre and post-op. Digital X-Ray PAPER NO. 196
analysis was performed and included: anatomic offset before Retrieval Analysis of Squeaking Alumina Ceramic-
and after surgery, Dorr classification and the area moment of
inertia on all cases. Independent sample T test, Pearson Chi on-Ceramic Bearings
Square were utilized; a p<0.005 was considered significant. The William Lindsay Walter, MD, Waverton, Australia
mean age was 67.8+/-1.4 SE. The overall prevalence of thigh pain (e – Stryker, e – Finsbury)
was 7%, the change in offset between groups was higher in the Steven M Kurtz, PhD, Philadelphia, PA (n)
group with no TP but no statistically significant differences were William J Hozack, MD, Philadelphia, PA (n)
found (0.23±0.49S.Dvs.0.22±0.34SD;p=0.12). Patients with TP Jonathan P Garino, MD, Philadelphia, PA (n)
had significantly poorer bone quality compared with those
Michael A Tuke, Surrey, United Kingdom (n)
without TP (29%vs.5%; p=0.023). Significant differences in all 4
measurements of stiffness were found. Lower stiffness in all Javad Parvizi, MD, Philadelphia, PA (n)
measures, axial stiffness (59.7±8.4SD vs. 80.6±24.7SD; George Kirsh, MD, Sydney, NSW Australia (n)
p<0.001), medial-lateral bending stiffness (30.4±9.8SD vs. Andrew M Ellis, MD, Willoughby, NSW Australia (n)
54.4±31.6SD; p<0.001), antero-posterior bending stiffness Abstract: Squeaking is a rare complication of hard-on-hard hip
(30.2±7.9SD vs. 54.5±32.1SD;p<0.001) and torsional stiffness bearings. Occasionally the noise is troublesome enough to warrant
(60.6±15.4SD vs. 108.9±62.2SD; p<0.001) was associated with revision surgery. The purpose of this study is to contribute to the
increased TP. Our study clearly demonstrates that patients with understanding of the mechanism(s) underlying squeaking. We
poor bone quality and or decreased bone axial and torsional analyzed 10 alumina ceramic-on-ceramic bearings from squeaking
stiffness have an increased risk of having TP postoperatively. The hips collected at revision surgery. Revision was for squeaking with
group in which the offset was increased from the preoperative or without pain. Six of the 10 patients were male, average patient
anatomic offset demonstrated a trend having less thigh pain. age was 49. Bearings were retrieved after an average of 27 months
in service (11 to 61 months). There were 4 different designs of
PAPER NO. 165 acetabular component from 2 different manufacturers. Nine have
◆Calcium Phosphate Paste Can Prevent Thigh Pain an elevated metal rim which is proud of the ceramic and one does
not. All 10 bearings showed evidence of edge loading wear. Mean
after Cementless THA dimensions of the wear patch were 39mm by 13mm on the
Tomotaro Sato, MD, Nagoya, Japan (n) acetabular component and 33mm by 14mm on the femoral
Daihei Kida, MD (n) heads. Six of the 10 implants also had evidence of impingement of
Atsushi Kaneko, Tokyo, Japan (n) the neck femoral neck against the elevated metallic rim or the
Masami Tsukamaoto, MD (n) ceramic insert or both. There was no chipping or fracture of any of
Yoshito Eto, MD, Tokyo, Japan (n) the ceramic components. Squeaking is a recently recognized
complication of hard or hard bearing surface. This retrieval study is
Abstract: One of major problems in Total Hip Arthroplasty is
the first of its kind, to our knowledge attempting to unravel the
thigh pain. We have examined the effect of femoral canal injec-
mechanism of this undesirable complication. Although impinge-
tion of Calcium Phosphate Paste (CPP) for cementless THA. CPP
ment seems to be present in majority of cases, the latter does not
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

is a mixture of alpha Tri-Calcium Phosphate, Tetra-Calcium

seem to be necessary. Edge loading wear was the common factor in
Phosphate, Calcium Hydrogen Phosphate and Hydroxyapatite.
all cases and this may prove to be a critical mechanism.
This paste harden in 10 minutes and its stiffness increases to
80Mpa in 3days. Cementless THA were performed in 78
PAPER NO. 197
osteoarthritic hips from 1999 to 2004. Eight of patients were
male and 70 were female, average age were 62.1 years old ranged Noisy Ceramic Hip: Is Component Malpositioning
39 to 81.In 19 hips, CPP (10-12g) were filled as a femoral canal the Problem?
filler around the distal end of stem. In 59 hips, as a control, no William J Hozack, MD, Philadelphia, PA (e – Stryker)
CPP were filled in the canal. Proximal part of the stem was HA
Camilo Restrepo, MD, Philadelphia, PA (n)
coated on rough metal surface. No thigh pain were observed in
CPP group patients. In control group, nine hips (15.3%) showed
Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
thigh pain (p<0.026), but walking disability and pain were mild James J Purtill, MD, Philadelphia, PA (n)
in the first year and improved by the next year. CPP filled in the Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
canal were absorbed slowly on X-ray film, but prevention of thigh Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
pain lasts for long time maximum 4 years. No infections and Abstract: Noisy/squeaking ceramic on ceramic (COC) bearing
pulmonary embolism were observed in both series. Filling CPP surface is a recently recognized problem associated with THA.
into the gap between stem tip and femoral canal is useful tech- Multiple theories for etiology of this complication have been
nique to prevent thigh pain after cementless THA. proposed. Some investigators implicate acetabular component
malpositioning as the main potential cause. The intention of this
case-controlled study was to evaluate acetabular component
positioning in patients with squeaking and non-squeaking COC
THA. Noise (squeaking) has occurred in 29 out of 1056 (2.6%)
patients undergoing COC THA at our institution. These patients
were strictly matched, in a 1 to 2 ratio, with non-squeaking COC
hips. The matching criteria included age, gender, BMI, surgeon,
date of surgery, prosthesis type, femoral head size, and acetabular
liner size. Radiographic evaluation to determine the position of
the acetabular component was performed using OrthoView®
(Southampton Hampshire, UK) software. CT scan to assess
component positioning was also used in the squeaker cohort, but

374 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 375

because of ethical and financial reasons CT scan in the control PAPER NO. 199
group could not be performed. There was no statistically signifi-
cant difference in the mean cup inclination (p=0.27) or cup
◆Fracture/Impingement Failures in Cementless
version (p= 0.69) between squeaker and non-squeaker hips. Ceramic on Ceramic Total Hip Arthroplasty
Further, the software was accurate in measuring the position of Takashi Nishii, MD, Osaka, Japan (n)
the acetabular component as the mean values obtained with the Nobuhiko Sugano, MD, Suita, Japan (n)
CT scan for cup version and inclination did not differ from radi- Hidenobu Miki, MD, Suita, Japan (n)
ographic measurements significantly. The main etiology of Takashi Sakai, MD, Osaka, Japan (n)
squeaking COC THA remains elusive at the present time.
Takehito Hananouchi, MD, Suita, Japan (n)
Although component malpositioning and impingement could
potentially be an important contributing factor, the latter cannot
Hideki Yoshikawa, MD (n)
be the sole reason for noisy ceramic hips based on the findings of Nobuo Nakamura, MD, Osaka, Japan (n)
this study. Further investigations to elucidate the etiology of this Mitsuyoshi Yamamura, MD, Suita, Japan (n)
undesirable complication is warranted. Daiki Iwana, MD, Osaka, Japan (n)
Abstract: Ceramic on ceramic (C/C) bearing is a promising inno-
PAPER NO. 198 vation to reduce wear debris, but has a concern of ceramic frac-
The Squeaking Hip: An Under-Reported Phenomenon ture or neck-liner impingement. The purpose of this study was
to evaluate clinical results of C/C total hip arthroplasty (THA)
of Ceramic-on-Ceramic Total Hip Arthroplasty with particular attention to fracture/impingement failures. Two
Christopher A Jarrett, MD, Atlanta, GA (*) hundred and one hips in 157 patients consecutively underwent
Amar S Ranawat, MD, New York, NY (*) a cementless C/C THA with taper-locked ceramic liner, and were
Matteo Bruzzone, MD, Torino, Italy (*) followed-up clinically and radiologically. Five patients died and
Jose A Rodriguez, MD, New York, NY (*) five were lost, and the remaining 188 hips were analyzed for a
Chitranjan S Ranawat, MD, New York, NY (*) mean follow-up of 7 years (5-9). The clinical results (Merle
Abstract: The first ceramic-on-ceramic total hip arthroplasty in d’Aubigne score) were excellent or good in 95.7% of hips, but 11
the U.S. became available for widespread use in March 2003. hips presented abnormal hip noise. Radiological follow-up
Early reports have demonstrated excellent results though a few showed no migration of the components except three acetabular
reports have noted the rare squeaking hip. Between March 2003 components, and no periprosthetic osteolysis except one acetab-
and May 2005, three surgeons performed 159 (143 patients) ular component and one femoral component. Notch formation
ceramic-on-ceramic total hips. Patients were followed prospec- on the posterior neck was observed in five hips. During the
tively using a self assessment questionnaire. A control group of follow-up, five hips were revised, including three hips associated
60 hips (48 patients) with a metal-on-polyethylene bearing was with fracture of ceramic liner rim. The survival rate at 7 years was
matched to the ceramic group. Radiographic evaluations were 97.7% when failure was revision. The eight hips with notch
made according to previously established criteria. 20% (31/143) formation or ceramic liner fracture, had high frequency of hip
of patients in the ceramic group report their hip makes some noise (75%) and had significantly higher cup abduction and
anteversion angles (p<0.05) than the other hips without failures.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

type of noise. 7% (10/143) describe the noise as an audible
squeak. Average HSS scores improved from 19.8 to 38.4 indi- The seven-year results of cementless C/C THA were favorable
cating excellent clinical results. 90% of patients had satisfaction with few cases of osteolysis, however, hip noise may be a clinical
rates greater than 8 out of 10. There were 3 dislocations (1.9%), sign of fracture/impingement failures. Cup placement with high
one of which squeaked and was revised for recurrent dislocation. abduction or anteverion angle should be avoided to prevent
There were no cases of deep sepsis. The incidence of some type fracture/impingement failures.
of noise amongst metal-on-polyethylene patients was 4%
(2/48). There were no squeaks in this group. There was no radi-
PAPER NO. 200
ographic loosening or malalignment.Squeaking in ceramic-on- The Effect of Metal Staining on Alumina-Alumina
ceramic total hip arthroplasty is more common than has been Hip Simulation Wear
reported. The causes and implications of squeaking are yet to be
B Sonny Bal, MD, Columbia, MO (c – Zimmer)
determined. Nonetheless, patients considering ceramic-on-
ceramic bearings should be counseled accordingly.
Michael Steven Hughes, MD, Columbia, MO (n)
Stephen Li, PhD (n)
Mohamed Rahaman, PhD (n)
Abstract: Contact of an alumina ceramic femoral head against a
metal component during THA can result in surface metal depo-
sition. With recurrent THA dislocation, metal staining can be
associated with damage to the alumina surface as well. However,
the impact of these changes on ceramic-ceramic articulations in
THA remains unclear. We compared the wear rates of three
groups of alumina articulations; Group A (n=4): New, never
implanted components; Group B (n=4): Retrieved heads with
inadvertent metal staining from a single contact of alumina with
metal during THA; and Group C (n=2): Metal stained alumina
heads from THA with recurrent dislocations. All femoral heads
were run against new, unused alumina liners for five million
cycles on a Shore Western Hip Simulator. After 5 million cycles
on the Simulator, there was no measurable wear of the heads or
liners for new alumina heads, and those stained after a single

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
375
PPSE 07:Layout 1 1/12/07 1:40 PM Page 376

contact against the acetabular cup during THA (Groups A, B). performed between 1981 and 1985. The mean age at surgery was
The two heads in Group C had metal-staining associated with 57 years (38-64). The cohort was reviewed more than 20 years
surface scratching related to recurrent THA dislocations. These after surgery to determine osteolysis, wear and function in both
two had wear rates of 0 and 1.0 mg/million cycles, with corre- hips. Osteolysis was measured on anteroposterior pelvic X-rays
sponding alumina liner wear of 0.08 and 2.9 mg/million cycles and with three dimensional volume based on CT scans at the
. These results suggest that it is the surface roughening and not most recent follow-up. On ceramic-ceramic hips no osteolysis
the metal staining that contributed to the increased wear of was detected on X-ray, and with CT scan three acetabular lesions
alumina articulations. Superficial metal staining of alumina and one calcar lesion were detected. On ceramic-polyethylene
bearings during THA appears to be a benign process that does hips, using CT scan, 21 acetabular lesions and 21 calcar lesions
not increase bearing wear. were detected, versus 5 acetabular lesions and 17 calcar lesions
on X-ray. The ceramic-ceramic hips had significantly less osteol-
PAPER NO. 201 ysis in square millimeters on X-ray (average 25 for ceramic-
WITHDRAWN ceramic versus 98 for ceramic-polyethylene) and in cubic
millimeters on CT scan (170 for ceramic-ceramic versus 1290 for
PAPER NO. 202 ceramic-polyethylene). Wear was undectable on ceramic-ceramic
hips (using the Livermore technique and digital calipers) as
Comparison of Metasul and Durasul Acetabular compared to ceramic-polyethylene (mean of 1,6 mm). The
Liners in Cementless Total Hip Arthroplasty ceramic-polyethylene hips had however significantly higher
William T Long, MD, Inglewood, CA (a – Zimmer) Harris hips scores (92.6 for ceramic-polyethylene versus 87.1 for
Lawrence D Dorr, MD, Inglewood, CA (n) ceramic-ceramic) and significantly SF 36 health survey scores
(102.3 versus 92.1) Ceramic-on-ceramic bearing displayed lower
Leigh E Sirianni, OPA-C, Inglewood, CA (n)
wear rates and less osteolysis. However patients prefered their
Aamer Malik, MD, Inglewood, CA (n) ceramic-on-polyethylene hips.
Abstract: This study compared the clinical performance of total
hip arthroplasty using the Metasul metal-on-metal bearing PAPER NO. 204
surface to the Durasul highly-cross linked polyethylene acetab-
ular insert articulating with a cobalt-chrome head. In a random-
A Double-Blind RCT Of X-Linked vs Conventional
ized prospective study, 78 patients (96 hips) underwent total hip PE in THA: A 2-4 Year Follow-Up
arthroplasty from 2002 to 2003. All of the operations were J Geoffrey Horne, MBChB, Wellington South, New Zealand
performed using an uncemented acetabular shell with the (a – DePuy)
Metasul insert in 50 hips and the Durasul liner in 46 hips. Peter Andrew Devane, MD, Wellington, New Zealand
Average follow up for the study group is three years with an (a – DePuy)
average Harris hip score (HHS) for the Metasul group being
Abstract: The results of a randomized, prospective double
98.45 ± 2.7 and 98.50 ± 3.2 for the Durasul group. The average
blinded (surgeon and patient) trial (RCT) of cross-linked versus
Harris pain score for the Metasul group was 43.1± 1.6 and for
conventional polyethylene, using a 100% reproducible method
the Durasul group it was 43.5± 1.2. Seventy two (92%) patients
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

of PE wear measurement, are reported. After Ethics Committee

reported the postoperative outcome as excellent and 6 (8%)
approval, the two authors enrolled 124 patients onto an RCT
reported the outcome as very good using the patient self-assess-
comparing Enduron (non cross-linked PE) and highly cross-
ment. There were no statistically significant differences in the
linked Marathon PE (DePuy, Leeds, UK). Randomization was
HHS, pain score, or patient self-assessment between the Metasul
performed by the circulating nurse determining whether the
and Durasul groups. Linear wear could not be measured on radi-
patient received an Enduron or Marathon liner appropriate to
ographs of the metal-on-metal articulation, and the average
the size of the metal shell. Liners were implanted into identical
linear wear measured with the Durasul articulation was
metal shells (Duraloc 300) with one screw. They articulated with
0.012mm/yr. No hip had radiographic evidence of osteolysis,
identical 28mm CoCr femoral heads and cemented Charnley
and there were no loose components. Postoperative complica-
Elite femoral stems. All patients were followed with anteropos-
tions consisted of three (3.1%) dislocations, one (1.4%) deep
terior and lateral radiographs at 3 days, 6 weeks, 3 months 6
infection and one (1.4%) periprosthetic femur fracture. The data
months, 1, 2, 3 and 4 years. PE wear was measured with PWAuto,
supports our hypothesis that there is no difference in clinical or
a validated computer-assisted technique with 100% repro-
radiographic results between Metasul and Durasul acetabular
ducibility and accuracy of ±0.13mm. 113 patients had appro-
inserts total hip arthroplasty.
priate radiographs and follow-up interval. Mean follow-up was
PAPER NO. 203 2.6 years (range 2 ‘ 4 years). Fifty-eight patients received Enduron
liners and 55 patients received Marathon liners. At 6 months
Ceramic-Ceramic Versus Ceramic-Polyethylene (E=0.32, M=0.31mm) and one year (E=0.37, M=0.31mm) the
Bearing On The Contralateral Hip three-dimensional PE wear was identical in both groups.
Philippe Hernigou, PhD, Creteil France, France (n) Thereafter, all PE wear measurements showed a significant differ-
Georges Laval, MD (n) ence in PE wear between the two groups. Wear of the conven-
tional Enduron group continued (0.51mm at 2 years, 0.70 at 3
Marc Antoine Rousseau, San Francisco, CA (n)
years, 0.97 at 4 years), while the crosslinked Marathon group
Abstract: 21 patients with bilateral arthroplasty (one ceramic- showed virtually no further wear (0.32mm at 2 years, 0.32mm
ceramic and the contralateral ceramic-polyethylene) who had at 3 years, 0.33mm at 4 years). This is the first study to confirm
already survived 20 years without revision and without loos- that Hip Simulator predictions of cross-linked PE wear can be
ening of both hips were identified. All the femoral heads were reproduced in-vivo
alumina 32 mm and made by the same manufacturer. All the
cups (ceramic or polyethylene) and femoral implants were
cemented and made by the same manufacturer. Both hips were

376 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 377

PAPER NO. 205 cantly (p<0.01) lower for Duration [0.088 ± 0.03 mm/yr (0.02-
Excessive Polyethylene Wear with the Zirconia 0.14)] than conventional PE [0.142 ± 0.07 mm/yr (0.05-0.31)]. This
reduction (-38%) compared well to the simulator (-45%) and did
Femoral Head in Total Hip Arthroplasty not change over time (-33% at 5-years). Radiolucencies and signs of
Yasuharu Nakashima, MD, Fukuoka, Japan (n) osteolysis were also less. Concerns about deteriorating wear
Seiya S Jingushi, MD, Fukuoka, Japan (n) performance with crosslinked and annealed PE seem unfounded as
Toshihide Shuto, MD, Fukuota, Japan (n) the wear reduction is maintained at 8 years. The agreement between
Takuaki Yamamoto, MD, Fukuoka, Japan (n) in-vivo and simulator wear reduction validates simulator predic-
Iwamoto Yukihide, Fukuoka, Japan (n) tions for newer generations of crosslinked PE.
Abstract: The purpose of this study was to compare the polyeth- PAPER NO. 207
ylene wear and the prevalence of the periprosthetic osteolysis in
total hip arthroplasty with zirconia femoral head versus alumina Minimum 4 Years Prospective Randomized
heads. Matched pair analysis with 100 hips was performed with Penetration Rate of Highly-Cross-linked
two femoral head groups (Zirconia and Alumina). Each group Polyethylene
had 50 hips with no significant differences regarding any param-
eters except femoral head materials. The mean follow up periods Moussa Hamadouche, MD PhD, Paris, France (e – Zimmer)
were 10.1 years (8-11 years). Both groups had the identical Phillip Triclot, MD, Fougeres, France (c, e – Zimmer)
conventional polyethylene liners. The true linear and volumetric Guillaume Grosjean, MD, Paris, France (n)
polyethylene wear rates were measured using the CAD soft ware Firas El Masri, MD, Paris, France (n)
(Vector Works, Tokyo, Japan). The surface roughness and the rate Jean-Pierre Courpied PhD, Paris, France (n)
of phase transformation were also measured with the 8 retrieved Abstract: The purpose of this prospective randomized study was to
zirconia femoral heads from another series of the patients. compare the penetration rate of polyethylene inserts of identical
Zirconia showed significantly more linear wear than Alumina design but different levels of cross-linking in a consecutive series
(0.16 versus 0.08 mm/year) and also more volumetric wear of hybrid total hip arthroplasty at a minimum 4-year follow-up.
(53.0 versus 27.9 mm3/year). Periporsthetic osteolysis was Between August 2000 and December 2001, 102 patients (102
observed in 8hips (16%) in Zrconia and 2 hips (4%) in hips) with a mean age of 69.2 years were randomized to receive
Alumina. Surface analysis showed the time dependent increase either highly cross-linked (Durasul®, 49 hips) or contemporary
of the phase transformation to monoclinic phase of the retrieved (Sulene®, 53 hips) polyethylene inserts. Other parameters,
zirconia femoral heads. It is estimated that 30% of the phase including the 28 mm cobalt-chrome femoral head, the cementless
transformation occurred in 15 years. But no change was detected cup (Fitmore®, Zimmer) and cemented stem (Emeraude®,
regarding the surface roughness. Our in vivo findings showed Zimmer), were identical in both groups. The primary criterion for
that the zirconia femoral head resulted in the higher rates of evaluation was head penetration measurement, using the Martell
polyethylene wear and subsequent more prevalence of osteolysis system. At the minimum 4-year follow-up evaluation, 34 hips in
although zirconia head have shown the high wear resistance the Durasul® group and 30 hips in the Sulene® group had
data in vitro. The relationship between the phase transformation complete radiologic data available for analysis (median follow-up

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

and polyethylene wear was unclear. of 4.8 and 4.9 years in the Durasul® and Sulene® group, respec-
tively). The median femoral head penetration rate was 0.029
PAPER NO. 206 mm/year in the Durasul® group versus 0.123 mm/year in the
Crosslinked Versus Conventional Polyethylene in Sulene® group (Mann and Whitney test, p = 0.0027). The median
THA: 8-year Prospective Randomized Evaluation volumetric penetration rate was 7.99 mm3/year in the Durasul®
group versus 41.93 mm3/year in the Sulene® group. The yearly
Bernd P Grimm, PhD, Aachen, Germany volumetric penetration rate was 80% lower in the Durasul® group
(a – Stryker, Biomet) (Mann and Whitney test, p = 0.0034). This study demonstrated a
Ide Christiaan Heyligers, MD, Heerlen, Netherlands significant reduction in the yearly linear and volumetric femoral
(a – Stryker, Biomet) head penetration in highly cross-linked polyethylene. Longer-term
Alfons J Tonino, PhD (a – Stryker) results are needed to warrant that these early data will generate less
Abstract: Simulator wear studies of crosslinked PE show promising occurrence of osteolysis.
results but long-term clinical investigations addressing concerns
about in-vivo aging, PE deterioration, late wear and osteolysis are PAPER NO. 208
scarce. This study reports the longest published follow-up Reduction of Osteolysis with Crosslinked
comparing conventional to crosslinked PE. Crosslinked PE (Stryker Polyethylene at Five Years
Duration: 3MRad gamma irradiation in N2, annealing) was
compared to conventional PE (3MRad gamma irradiation in air) in Rudi Bitsch, MD, Heidelberg, Germany (a – DePuy)
a MTS hip simulator and a prospective randomized clinical study Thomas P Schmalzried, MD, Los Angeles, CA (b – DePuy)
involving 48 THA patients (Stryker ABG-II stem and cup, 28mm Christian Heisel, MD, Heidelberg, Germany (a – DePuy)
ball diameter) with a mean follow-up of 8 (7-9) years. Patients were Scott T Ball, MD, San Diego, CA (a – DePuy)
followed-up annually using the HHS, radiographs and wear meas- Mylene A Dela Rosa, BS (n)
urements applying a digital Livermore method. Forty patients (23 Abstract: Marathon crosslinked polyethylene (PE) has demon-
conventional, 17 Duration) were left for analysis (five premature strated low wear in short-term studies that approached the
deaths, 3 loss to follow-up). Both groups were statistically non- reduction predicted by wear simulators. With longer follow-up,
different (p>0.1) regarding age (63.9 years), gender, BMI, stem size, wear rate can be more accurately determined and radiographs
cup size, cup inclination and liner thickness leaving the insert mate- can be assessed for osteolysis. 32 patients received a crosslinked
rial as the only variable. Pre-op HHS (39.7) and post-op HHS PE liner (MarathonTM , DePuy, Warsaw, IN) and 24 hips a
(93.7) was also not different. At 8-years the wear rate was signifi- conventional PE insert (EnduronTM , DePuy, Warsaw, IN). True

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
377
PPSE 07:Layout 1 1/12/07 1:40 PM Page 378

wear rates were measured on radiographs using a linear regres- the largest possible femoral head, it was still way below the volu-
sion analysis of data generated with a validated computer- metric wear necessary for the osteolysis threshold. The range of
assisted technique. Patient activity was assessed by a motion was greater in hips with 38 or 44 mm femoral heads.
computerized two-dimensional accelerometer worn on the The largest femoral head size cannot protect against dislocation
ankle (Stepwatch, Cyma, Seattle, WA). Five year radiographs from the malposition of implants.
were assessed for osteolysis by three different orthopaedic
surgeons. The mean follow up time was 5.3 years (range: 3.9-7.0 PAPER NO. 210
years). MarathonTM PE had a volumetric wear rate of 15.9 mm³ Management of Polyethylene Wear associated with
/year (range: 0.3-84.3 mm³ /year, SD = 19.9 mm³ /year) and 9.5
mm³ /million cycles (range: 0.1-23.0 mm³ /million cycles, SD =
a Well-fixed Modular Cementless Shell in Revision
6.1 mm³ /million cycles). The group with EnduronTM PE had a THA
mean volumetric wear rate of 59.2 mm³ /year (range: 5.6-259.0 Carl T Talmo, MD, Waltham, MA (n)
mm³ /year, SD = 55.6 mm³ /year) and 29.1 mm³ /million cycles Young-Min Kwon, MD, Boston, MA (n)
(range: 2.2-70.9 mm³ /million cycles, SD = 15.5 mm³ /million Murali Jasty, MD, Boston, MA (n)
cycles). Volumetric wear rate in the MarathonTM group was 73%
Andrew A Freiberg, MD, Boston, MA (a, c – Zimmer)
lower than in the EnduronTM group (p=0.001). 8 of 24 hips
with EnduronTM liners had unanimously developed osteolysis.
Dennis W Burke, MD, Boston, MA (n)
Osteolysis was unanimously not apparent radiographically in William W Tomford, MD, Boston, MA (n)
any of the 32 hips with Marathon. Up to 7 years in vivo, Janet Dorrwachter, RN (n)
Marathon crosslinked polyethylene demonstrates a 73% relative Harry E Rubash, MD, Boston, MA (a, e – Zimmer)
reduction in volumetric wear rate which approaches the reduc- Henrik Malchau, MD, Boston, MA (a – Zimmer)
tion predicted by wear simulations. More importantly, however, Abstract: The options for management of polyethylene wear
is the absence of radiographically apparent osteolysis. Concerns with a well-fixed modular acetabular shell during revision THR
of an increased risk of osteolysis due to smaller particles from include liner exchange, cementing a new liner into the existing
crosslinked polyethylene are assuaged by this experience. shell and revising the shell. Liner dislodgement with the Harris-
Galante(HG) acetabular component has been reported. Success
PAPER NO. 209 rates with each of these techniques with the HG shell is
Primary Total Hip Arthroplasty Using the Largest unknown. Review of our arthroplasty database identified 128
Femoral Head Possible revision THR from 1993 to 2005 involving a well-fixed HGI or
HGII acetabular component with minimum 2 year follow-up.
Lawrence D Dorr, MD, Inglewood, CA (a, c – Zimmer) Preoperative clinical data and radiographs were reviewed along
Zhinian Wan, MD, Inglewood, CA (n) with follow-up radiographs, Harris Hip and EQ-5D Scores. The
Myriam Boutary, Burbank, CA (n) study end points were re-revision or radiographic failure of the
Leigh E Sirianni, OPA-C, Inglewood, CA (n) acetabular component. Three treatment cohorts were identified.
Abstract: Introduction: The use of large femoral head sizes In 67 hips the polyethylene liner was exchanged and the locking
tines bent in to prevent dislodgement. In 35 hips the well-fixed
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

should improve range of motion and stability of THA. This study

measured the clinical results and polyethylene wear from acetabular component was revised and in 26 hips a new liner
patients with THA using the largest femoral head size possible was cemented into the shell. 108 of a 128 hips were available at
with 5 mm thickness of Durasul highly X-linked polyethylene. an average follow-up of 5.1 years. Of the hips that underwent
Methods: A prospective study was conducted on 93 consecutive modular liner exchange at revision 14 hips(24%) required re-
patients with 105 hips with primary THA. 77 patients with 89 revision, 6 for liner dislodgement and 5 for progressive osteol-
hips had three year followup. A modular Durasul liner was used ysis and polywear. Of the hips that underwent revision of the
with the largest cobalt chrome femoral head possible to obtain well-fixed shell, 4(15%) required subsequent re-revision of the
the minimum thickness of the liner of 5 mm.11 hips had 28 acetabular component, 2 for dislocation and 2 for aseptic loos-
mm, 33 had 32 mm, 39 had 38 mm, and 6 had 44 mm femoral ening. 6 hips(29%) in the cemented liner group were re-revised,
head sizes. The polyethylene wear was measured radiographi- 4 for dislocation and 2 for loosening. Our data suggests that the
cally and the clinical outcome was judged by Harris Hip scores. most reliable treatment for polyethylene wear in the setting of
The results with these hips were compared with our series of revision THR with a well fixed Harris-Galante acetabular compo-
primary THA with Durasul liners and exclusively 28 mm nent is removal and revision of the well-fixed shell.
femoral heads and otherwise same implants (published).
Results: The clinical results by Harris Hip score did not differ PAPER NO. 466
between these patients and the control group of those with Arthroscopic Acetabular Labral Debridement in
exclusively 28 mm heads. No patient has a loose cup or stem.
Patients Older than Forty Years
One patient with one hip had a 38 mm head and two disloca-
tions. The acetabular anteversion was 4 degrees and revision Ryan Chen, MD, Saint Louis, MO (n)
increased anteversion 19 degrees successfully eliminating the John C Clohisy, MD, Saint Louis, MO (a – Zimmer)
dislocations. The polyethylene liner wear was 0.028± 0.022 Abstract: The purpose of this study was to evaluate the outcome
mm/year for the largest femoral head possible and had been of arthroscopic debridement of the acetabular labrum in
0.029±0.02 mm/year for the hips with exclusively 28 mm head patients older than forty years of age. Forty-nine patients older
(p=0.686). The volumetric wear was 17.6±12.5 mm3/year for than forty years (mean 51.8 years) underwent arthroscopic labral
this series with the largest femoral head size and was 26.6± 24.8 debridement. A control group consisting of fifty patients under
mm/year for those with exclusively 28 mm heads(p=0.04). the age of forty (mean 26.6 years) who underwent arthroscopic
Conclusions: The use of the largest femoral head size possible labral debridement was used for comparison. The older group
did not increase linear polyethylene wear up to 3 years after had a higher prevalence of early degenerative disease found on
THA. While the volumetric wear was greater for the group with preoperative plain radiography (53 vs. 10 percent, p equals

378 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 379

0.0001) as well as MRA (41 vs. 20 percent, p equals 0.02). PAPER NO. 468
Intraoperatively, the older group had more severe chondral Combined Hip Arthroscopy and Limited Open
disease of both the femur and acetabulum (p equals 0.0001).
Mean follow-up for the older and younger cohorts was 2.2 and Osteochondroplasty for Treating Impingement
2.3 years, respectively. The improvement in the modified Harris Disease
Hip score was less for the older cohort compared to the younger Lukas Zebala, MD, Saint Louis, MO (n)
cohort (change of 13.7 vs. 19.0, p equals 0.02). Good to excel- John C Clohisy, MD, Saint Louis, MO (a, e – Zimmer)
lent results were achieved in 75 percent of the younger patients
Sarah Hinkle, MPH (n)
but only 41 percent of the older patients. Nine (18 percent) of
the patients in the older cohort experienced relative rapid James Thomas McClure, MD, Hendersonville, TN (n)
progression of osteoarthritis and required subsequent total hip Jason F Robison, MD, Saint Louis, MO (n)
arthroplasty. Factors associated with poor outcome included Abstract: The purpose of this study is to evaluate the early results
increasing Tonnis grade (p equals 0.02), dysplasia (p equals of hip arthroscopy with combined limited open head-neck junc-
0.04), degenerative changes noted on MRA (p equals 0.01) and tion osteochondroplasty for the treatment of cam femoroac-
chondral disease of the acetabulum noted intraoperatively (p etabular impingement. Retrospective review of twenty-four
equals 0.009). Arthroscopic acetabular labral debridement in consecutive patients treated with combined hip arthroscopy and
patients older than forty years of age yielded unpredictable clin- limited open osteochondroplasty was performed. All patients
ical results at short-term follow-up. were treated for symptomatic cam femoroacetabular impinge-
ment. There were 19 males and 5 females with an average age of
PAPER NO. 467 33 years. The average follow-up was 1.5 years (range, 1.0-3.1
Arthroscopic Femoral Osteochondroplasty for years). The modified Harris hip score improved from 63.8 to
92.3 (p<0.001) at last follow-up. The UCLA activity level score
Femoro-Acetabular Impingement increased from 6.2 to 8.3 (p=0.03) and the non-arthritic hip
Damian R Griffin, MD, Coventry, United Kingdom score rose from 69.3 to 87.4 (p<0.05). Twenty-three patients had
(b – Smith and Nephew, a, b – Corin, Wright) a good or excellent result and one patient had a fair result.
Abstract: Cam-type femoro-acetabular impingement (FAI) is Radiographically, femoral head-neck offset improved on the
increasingly recognised as a cause of mechanical hip symptoms cross-table (9.8 vs. 16.6, p<0.001) and frog-leg lateral (7.2 vs.
in young adults. It is likely that it is a cause of early hip degener- 15.1, p<0.001) views. Offset ratio improved on cross-table (0.16
ation. Ganz et al have developed a therapeutic procedure vs. 0.27, p<0.001) and frog-leg lateral (0.13 vs. 0.25, p<0.001) x-
involving trochanteric flip osteotomy and dislocation of the hip, rays. The alpha angle was reduced from 60.5 to 37.6 (p<0.001)
and have reported good results. We have developed an arthro- on cross-table lateral x-rays, and from 66.5 to 38.1 (p<0.001) on
scopic osteochondroplasty to reshape the proximal femur and frog-leg lateral x-rays. Major complications included 1 superficial
relieve impingement. Fifty patients who presented with mechan- wound infection and 1 deep vein thrombosis. Combined hip
ical hip symptoms and had demonstrable cam-type FAI on radi- arthroscopy and limited open osteochondroplasty of the
ally-reconstructed MR arthrography, were treated by arthroscopic femoral head-neck junction is a safe and effective treatment of
osteochondroplasty. Ten patients had a postoperative CT; from focal, anterior femoroacetabular impingement at short term

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

these images flexion and internal rotation range was tested in a follow-up. Mid and long-term evaluation will be essential to
virtual reality (VR) model to determine adequacy of resection. document the durability of this surgical technique.
All patients were followed up for a minimum of one year, and
post-operative Non-Arthritic Hip Scores (NAHS, maximum PAPER NO. 469
possible score 100) compared with pre-operative NAHS. Mean Arthroscopic Treatment of Cam-Type Femoro-
operating time was 110 minutes. 31 patients were discharged on Acetabular-Impingement Secondary to Pediatric
the day of surgery, the remainder on the following day. There
were no complications. All patients were asked to be partially Hip Disease
weight-bearing with crutches for four weeks but most returned Victor Manuel Ilizaliturri Jr, MD, Mexico City, Mexico
to work within two weeks. The VR models showed satisfactory (c – Smith and Nephew)
resection, although there was clear evidence of improved preci- Javier Camacho-Galindo, MD, Mexico City, Mexico (n)
sion with practice. Symptoms improved in all but two patients, Eduardo Acosta-Rodriguez, MD (n)
with mean NAHS improving from 54 preoperatively to 87 at one
Abstract: Femoro-acetabular-impingement is an etiology for hip
year. The two patients who did not improve, were both found to
osteoarthritis. Two types of Femoro-acetabular-impingement are
have unexpectedly extensive acetabular articular cartilage
recognized: Pincer-impingement and Cam-impingement caused
damage. Arthroscopic femoral reshaping to relieve FAI is
by deformity of the neck-head femoral off-set. We present a
feasible, safe and reliable. However it is technically difficult and
consecutive series of patients with Cam-impingement secondary
time-consuming. The results are comparable to open dislocation
to pediatric hip disease treated with arthroscopy. Hip arthroscopy
and debridement, but the arthroscopic procedure avoids the
was performed by the lateral approach with traction to treat the
prolonged disability and the complications associated with
central compartment. Traction was released and an Arthroscopic
trochanteric flip osteotomy.
anterior capsulectomy performed to expose the bump at the
anterolateral femoral neck, which was removed using a spherical
arthroscopy-burr with arthroscopic and fluoroscopic visualiza-
tion. Full range-of-motion was allowed and weight-bearing
delayed for 6 weeks. WOMAC questionnaires were done before
surgery and at follow-up of 2 years. Fourteen hips, 13 patients, 7
female and 6 male treated between January 2003 and January
2004 presented symptomatic Cam-impingement (8 slipped-
capital-femoral-epiphysis, 4 Perthes and 2 Development-hip-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
379
PPSE 07:Layout 1 1/12/07 1:40 PM Page 380

dysplasia). AP-pelvis and Lowenstein views were taken. 11 PAPER NO. 471
patients had CAT-Scans and 2 had MR-arthrograms of the Proton Magnetic Resonance Spectroscopy as a
affected hip.Head-neck remodeling was successful and demon-
strated in the postoperative x-rays. Range-of-motion improved Prognostic Factor of Femoral Head Avascular
and WOMAC scores improved 9 points average at last follow-up. Necrosis
We had no neck fractures or avascular necrosis.Articular Chun-Han Hou, MD, Taipei, Taiwan (n)
pathology mainly at the acetabular cartilage and anterior labrum Tiffany Shih, MD, Taipei, Taiwan (n)
was found and treated in every case. Cam-impingement
Chien-chung Chiang, MD, Taipei City, Taiwan (n)
secondary to pediatric hip disease was successfully treated using
arthroscopy. Surgical hip dislocation and open remodeling of Ming-Hsiao Hu, MD, Taipei, Taiwan (n)
impingement deformities is the standard of treatment for Rong-Sen Yang, MD, Taipei, Taiwan (n)
Femoro-acetabular-impingement. Arthroscopic remodeling is an Sheng-Mou Hou, MD, Taipei, Taiwan (n)
attractive alternative, but has a step learning curve. Ying-Ding Li, MD (n)
Chieh-Yu Liu, PhD (n)
PAPER NO. 470 Abstract: Proton magnetic resonance spectroscopy (MRS) can
A New Minimal Invasive Approach for the measure the lipid and water components within bone marrow
Periacetabular Osteotomy: Technique and Results accurately. Our previously published study revealed significant
MRS differences between the intact femoral heads of patients
Anders Troelsen, MD, Lystrup, Denmark (n) with unilateral avascular necrosis(AVN) and healthy femoral
Brian Elmengaard, MD, Aarhus, Denmark (n) heads of the control group. The purpose of this study is to follow
Kjeld Soballe, MD, Aarhus, Denmark (n) up these patients and try to use the MRS data as a prognostic
Abstract: Minimal invasive surgery (MIS) seems to be part of tool. MRS was performed on the intact hips of 38 patients with
future orthopaedic solutions. Currently, most approaches for the unilateral femoral AVN. They were followed and MRS study was
periacetabular osteotomy (PAO) are characterized by relatively performed after at least two years. The lipid and water spectrum
extensive incisions, dissection and detachment of muscles. We on the MRS was further divided into three peaks, at 2.1ppm,
have developed a new MIS approach for the PAO. The purpose of 1.2ppm and 1.0ppm . Three variables were used to describe each
the study is to present the surgical technique, results and to peak: integration, amplitude, and line width. The completeness
compare it to the ilioinguinal (II) approach. The new MIS tech- of epiphyseal scar was also recorded as a prognostic factor. 10.5%
nique is a trans-sartorial approach using a three inch skin inci- (4/38) patients developed a new AVN lesion on the previous
sion. Previously the II approach was used. From 1999-2006 a intact femoral heads in a two-year follow-up period. They are all
total of 215 patients with acetabular dysplasia were operated by male. In lipid peaks at 2.1 and 1.0ppm, the integration showed
the same surgeon in two successive time periods with the II (97) significant differences between these four patients and the rest
and the trans-sartorial (118) approaches. No supplemental 34 patients (p<0.05). In the lipid peak at 2.1ppm, the amplitude
surgery was performed. The two approaches are retrospectively showed significant differences (p<0.05). The risk of AVN
compared regarding transfusion requirements, perioperative progression is not related to the completeness of epiphyseal scar.
measures and complications. Data are compared by Kruskal-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

The lipid peaks of MRS on the femoral head at risk of AVN can
Wallis Test and are presented as median and interquartile range. predict its prognosis of possible progression into AVN, as early
The trans-sartorial approach significantly reduced days of admis- as two years.
sion (8 (7-9) vs. 10(8-13), p<0.0001) duration of surgery (70(60-
75) min vs. 100(82.5-120) min, p<0.0001), perioperative blood PAPER NO. 472
loss (200(150-350) ml vs. 450(325-700) ml, p<0.0001) and the Novel Tissue Engineering Technology for the
percentage of patients receiving blood transfusion (18.6 % vs.
3.4%). Of severe neurovascular, infectious and technical compli- Treatment of Large Osteonecrotic Lesion of
cations none occurred in the trans-sartorial group and 3 cases of Femoral Head
arterial thrombosis were seen in the II group. Our shift to the Shin-Yoon Kim, MD, Daegu, Republic of Korea
trans-sartorial approach was rewarding as the duration of surgery, (a – Ministry of Health and Welfare, Korea, Ministry of
perioperative blood loss and transfusion requirements were Commerce, Industry and Energy, Korea)
reduced. A safe MIS technique is introduced for PAO.
Seung Hun Baek, MD, Daegu, Republic of Korea (n)
Eui-Hyun Park, MD (a – Ministry of Health and Welfare,
Korea, Ministry of Commerce, Industry and Energy, Korea)
Byung Woo Min, MD, Daegu, Republic of Korea (n)
Hee Joong Kim, MD, Seoulster, Republic of Korea (n)
Keun Tak Suh, MD, Seoul, Republic of Korea (n)
Abstract: Preservation of the femoral head with large, laterally-
located osteonecrotic lesions is very difficult. We introduce novel
tissue engineering technique to regenerate the necrotic bone of
these difficult cases. Ten milliliters of bone marrow was aspirated
from iliac crest and mononuclear cells were collected. These cells
were expanded and differentiated to osteoblasts using the
osteogenic media and autologous serum for 2-4 weeks ex vivo.
Porous bead form scaffolds were made of calcium metaphos-
phate(CMP) and cells were seeded in a density of million/ml³
into 20 to 30 beads for 1 hour. The necrotic area was curetted
and the beads were implanted through core tract to 9 hips in 7

380 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 381

patients(Steinberg IIc in 5 hips and IVc in 4 hips; Japanese improves gait. We assessed the clinical and functional affect total
Investigation Committee C1 in 4 hips, and C2 in 5 hips). The hip replacements surgery has upon low back pain. In this
tract was blocked with a CMP rod. The age of the patients ranged prospective clinical study twenty five consecutive adults sched-
from 16 to 37. Associated factors were; steroid-induced in 4 hips, uled for total hip replacement surgery due to severe hip joint
idiopathic in 3 hips, alcohol abuse in 1 hip, and posttraumatic osteoarthritis were recruited. The 25 study participants included
in 1 hip. Kerboul combined necrotic index was more than 200° 15 females and 10 males with a mean age of 67.4 years (range
in all hips (range, 200° to 380°). Minimum follow-up period 32-84 years). Patients included in this study had to demonstrate
was three years(range, 3 to 4 years). Two IIc lesions progressed to clinical evidence of debilitating hip pain, limited range of
IVc; one with dome depression>2mm and one with <2mm. The motion and radiographic changes characteristic of severe hip
other 7 hips did not progress radiographically. Follow-up radi- joint osteoarthritis. Exclusion criteria included previous hip
ographs showed regeneration of necrotic bone in 8 hips. Tissue and/or spinal fusion or instrumentation surgery. All patients
engineering technique using the bone marrow and CMP scaffold were clinically assessed by an independent internal medicine
was very promising strategy for the treatment of large physician including a detailed, thorough history and physical
osteonecrotic lesions of femoral head. examination of both the hip and spine (including hip range of
motion and the presence and degree of flexion contracture).
PAPER NO. 473 Functional outcome scores were assessed separately for the hips
Back Pain and Total Hip Arthroplasty: A Prospective and for the spine. The Harris Hip Score was used to evaluate hip
related symptoms in addition to the visual analogue scale specif-
Natural History Study ically for hip pain. The Oswestry spinal disability score was used
Javad Parvizi, MD, Philadelphia, PA (n) to evaluate spine related symptoms in addition to the visual
Grigory Goldberg, MD, Philadelphia, PA (n) analogue scale specifically for low back pain.history. Physical
Alan Sander Hilibrand, MD, Philadelphia, PA (n) examination and functional scores were assessed preoperatively
Richard H Rothman, MD, Philadelphia, PA (a – Stryker) and compared with those obtained when patient achieved inde-
Aidin Eslampour, MD, Philadelphia, PA (n) pendant ambulation no less than 3 months following THR.
Abstract: Many patients with DJD of the hip may have co-exis- Both hip pain VAS scores and harris hip scores were significantly
tent spinal arthritis. This prospective study sought to determine: better following THR. Mean hip pain VAS scores were 7.08
how hip arthritis commonly presents, the incidence of low back before and 2.52 after THR surgery (p<0.01). Harris hip scores
pain- as identified by patients- before and after THA and the were 45.74 before and 81.8 after the surgery (p<0.01). Both low
correlation between LBP and hip arthritis. 344 consecutive back pain VAS scores, as well as oswestry spinal disability scores
patients undergoing THA were recruited prospectively at a single were significantly better following total hip replacement surgery.
institution. A detailed questionnaire containing diagrams on Mean low back pain VAS scores were 5.04 before and 3.68 after
which the patient could draw out the site of their pain was THR surgery (p=0.013). Oswestry spinal disability scores were
administered to all patients preoperatively and postoperatively. 36.72 before and 24.08 after total hip replacement surgery
Detailed clinical, radiographic, and cross sectional imaging of all (p=0.02). Low back pain was alleviated and spinal functional
the patients were reviewed in detail by a hip surgeon, a spine assessment indexes were significantly improved following total
hip replacement surgery. This study, while pointing to the well

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

surgeon, and a neurologist. 170 patients (49.4%) had true LBP
which resolved in 63 patients (37%). Of the remaining 107 known clinical association between hip and spine pathology, is
patients the back pain was of the same intensity following THA among the first studies that demonstrates the clinical benefits
in 33 patients (30%) and had decreased in 74 (70%) patients. total hip replacement surgery has upon back pain.
22 of the 33 patients with continued LBP were known to have
PAPER NO. 475
spine pathology. 35 patients developed LBP after THA.18
patients in the latter group were investigated further and 12 were Dislocation Following Total Hip Arthroplasty in
found to have severe previously unrecognized spine pathology. Patients with Spinal Deformity
Hip and spine arthritis often co-exist. Majority of patients with
Juan M Raposo, MD, Rochester, MN (n)
‘back’ pain experience a complete resolution of their pain
David G Lewallen, MD, Rochester, MN
following THA so long as prior spine pathology did not exist.
THA seems to be beneficial in reducing the symptoms even for (a, b, c – Zimmer, b – DePuy)
those with a pre-existent LBP and spine pathology. A number of Fazel Khan, MD, Rochester, MN (n)
patients may develop LBP following THA that may relate to Robert Eastlack, MD, San Diego, CA (n)
unidentified spine pathology. Patients with true LBP may benefit Michael J Yaszemski, MD, PhD, Rochester, MN
form evaluation of their spine prior to THA. (e – Wyeth, Isotis, Bonwrx)
Abstract: The adverse effects of spine deformity on hip stability
PAPER NO. 474 following arthroplasty procedures has been postulated but not
Hip-Spine Syndrome: The Effect of Total Hip documented. The purpose of this study is to report the rate of
Replacement Surgery upon Low Back Pain dislocation for primary total hip arthroplasties (THA) performed
in adult patients with documented spinal deformity. Our insti-
Peleg Ben-Galim, Houston, TX (n) tutional total joint registry identified 186(147 female, 39 male)
Tal Ben-Galim, MD (n) patients with a primary THA for osteoarthritis between 1990 to
Nahshon Rand, MD, Mevaseret-Zion, Israel (n) 2004 who also had a concomitant diagnosis of spinal deformity
Shmuel Dekel, MD, Ramht-Gat, Israel (n) (scoliosis, hypolordosis, hyperlordosis, kyphosis, lumbar flat-
Yizhar Floman, MD, Zion, Israel (n) back). Patients with a history of trauma, previous hip surgery, or
Abstract: Severe osteoarthritis of the hip causes abnormal spinal inflammatory arthritis were excluded. There were 221 (122 right,
sagittal alignment and balance as well as a wobbling gait and is 99 left) THAs with an average followup of 6 years (2 to 15.5
associated with low back pain. Total hip replacement surgery years). Mean age was 73 years (52 to 92). 12 hips (5.4 percent)
(THR) is effective in alleviating hip pain and function and dislocated at least once. Average time to dislocation was 2.5 years

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
381
PPSE 07:Layout 1 1/12/07 1:40 PM Page 382

(9 days to 9.5 years). 4 (3.0 percent) dislocated hips were PAPER NO. 477
performed through an anterolateral approach (133 hips), 8 (9.6 Impact of Direct to Consumer Advertising on
percent) from a posterior approach (83 hips), 0 from a trans-
trochanteric approach (1 hip), and 0 using a two-incision mini- Physician Attitudes and Behavior in Orthopaedic
mally invasive technique (4 hips). Re-operation for instability Surgery
was performed in 5 patients. To our knowledge, this is the first Kevin John Bozic, MD, San Francisco, CA (n)
series to document an increased dislocation rate following Amanda Smith, Res Dir, San Francisco, CA (n)
primary THA in patients with spinal deformity. At our institu-
Sanaz Hariri, MD, Boston, MA (n)
tion, from 1990 to 2004, the overall rate of dislocation for
primary THAs in patients without spinal deformity (6328 hips) Sanjo Adeoye, MD, MBA (n)
was 3.4 percent. In patients with spinal deformity we report an William J Maloney MD, Stanford, CA
increased rate of dislocation of 5.4 percent. (c – Wright Medical Technologies, Zimmer, a – Medtronic)
Brian S Parsley, MD, Houston, TX (a, d – DuPuy)
PAPER NO. 476 Harry E Rubash, MD, Boston, MA (a, c – Zimmer)
Impact of Payer Type on Resource Utilization, Abstract: Direct-to-consumer advertising (DTCA) has emerged as
Outcomes and Access to Care in Total Hip an influential factor in healthcare delivery in the United States.
The purpose of this study was to evaluate the attitudes and
Arthroplasty behaviour of hip and knee surgeons towards DTCA, and to
Kevin John Bozic, MD, San Francisco, CA (a – OREF) assess its impact on resource utilization, quality of care, and the
Nalini Govindarajan, MMS (n) doctor-patient relationship. A 36-question survey was sent to
Adrian Hinman, MD, San Francisco, CA (n) 737 orthopaedic surgeons with experience in hip and knee
Amanda Smith, Res Dir, San Francisco, CA (n) replacement surgery. Respondents were asked questions
Abstract: Previous investigators have reported disparities in regarding their opinions of and experiences with DTCA. The
access to orthopaedic care among different socio-economic and extent and direction of association between surgeon characteris-
ethnic groups. The purpose of this study was to evaluate the tics and survey responses were measured using appropriate
reasons for and consequences of disparities in access to care by statistical methods. The survey response rate was 49%. Over
comparing patient characteristics, clinical outcomes, resource 98% of respondents had experience with patients who had been
utilization, and physician reimbursement by payer type for exposed to DTCA,and 77% expressed concerns about patients
patients undergoing primary total hip arthroplasty (THA). being confused or misinformed as a result of exposure to DTCA.
Baseline demographic characteristics, social history, distance A majority of respondents reported feeling pressured to use a
travelled for care, clinical outcomes, resource utilization and particular surgical technique or type of implant based on a
surgeon reimbursement were compared by payer type for a patient request (53%) and that DTCA had an overall negative
group of 186 consecutive patients who underwent THA at a impact on their practice and their interaction with patients
single institution. Medicaid patients were more likely to be (74%). Opinions regarding DTCA were influenced by surgeon
African-American (p<0.05), Hispanic (p<0.05), single (p<0.05), training and demographics. DTCA has the potential to enhance
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

and have a history of tobacco, alcohol, and/or substance abuse patient education, improve the efficiency of doctor-patient inter-
(p<0.05) than their Medicare or commercial payer counterparts. actions, and encourage treatment compliance among patients.
After adjusting for age, Medicaid patients had significantly lower However, the majority of physicians surveyed believe the infor-
pre-operative and post-operative functional scores than mation contained in DTCA is inaccurate and misleading, which
Medicare or commercial patients (p< .0001). Improvement in could have a detrimental effect on the quality and efficiency of
clinical function was greater for Medicare and commercial payer orthopaedic care delivery and the doctor-patient relationship.
patients than for Medicaid patients (p<0.05).Resource utiliza- Further study is necessary to better delineate the risks and bene-
tion was significantly higher and reimbursement was signifi- fits associated with DTCA in orthopaedics.
cantly lower for Medicaid patients than for other payer groups
PAPER NO. 478
(p<0.05).Compared to other payer groups, Medicaid patients
had to travel twice as far to receive treatment (66.0 miles vs. 38.3 Guideline for Wait Time Thresholds for Total Hip
miles, p<0.01). Payer status is highly correlated with patient and Knee Replacement Surgery Based on Severity
demographic characteristics, clinical outcomes, resource utiliza- Robert Barry Bourne, MD, London, Canada (n)
tion, and reimbursement in THA. Complex social histories, high
Bert Chesworth, PhD (n)
resource utilization, and low reimbursement may contribute to
limited access to orthopaedic specialty care for Medicaid Susan Warner, BA (n)
patients, which could have a significant impact on pain and Nizar Mahomed, MD, Toronto, Canada (n)
function at the time of initial presentation and therefore clinical Abstract: The purposes of this study were (1) to determine the
outcome following THA. effect of severity, wait times and patient perspective on outcomes
and (2) to create an evidence-based prioritization tool. Patients
who received a primary hip or knee replacement were followed
forward from decision date for surgery to one-year follow-up (N
= 4437) and outcomes assessed according to baseline severity. At
decision date for surgery, patient baseline severity was captured
using the WOMAC disability questionnaire. Twelve to eighteen
months after surgery, a questionnaire (WOMAC, satisfaction)
was sent to patients to compare pre- and post-operative data.
The chance of a good outcome from TJR surgery gets worse as
wait times get longer.Baseline severity affects outcome more
than wait times. Patients with a baseline WOMAC less then

382 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 383

30/100 should have surgery within 3 months (20% patients)If PAPER NO. 480
surgery cannot be done within 3 months, then 3 priority levels Effect of Aprotinin on Transfusion and Blood Loss
are recommended: Priority I ‘ 1 month maximum (catastrophic
hip or knee condition); Priority II ‘ 3 months maximum in Elective Primary Total Hip Arthroplasty (THA)
(WOMAC <30) Priority III ‘ 6 months maximum (WOMAC Clifford W Colwell Jr, MD, La Jolla, CA
>30). The priority levels and wait time thresholds recommended (a – Bayer Healthcare, Inc.)
in this study are the result of an analysis of pre-operative severity Jacques E Chelly, MD, PhD (a – Bayer Healthcare, Inc.)
scores, the length of the wait and post-operative outcomes and David G Stevens, MD, Waterloo, Canada
are consistent with data from other sources. (a – Bayer Healthcare, Inc.)
PAPER NO. 479 Thomas Joseph O’Keefe, MD, Ann Arbor, MI
(a – Bayer Healthcare, Inc.)
MRI in the Diagnosis and Management of Richard Hall, MD, London, Canada
Periprosthetic Inflammation and Osteolysis (a – Bayer Healthcare, Inc.)
Following THA Javad Parvizi, MD, Philadelphia, PA
Herbert John Cooper, MD, New York, NY (n) (a – Bayer Healthcare, Inc.)
Amar S Ranawat, MD, New York, NY (e – DePuy, Stryker) Andrea Nadel, PhD (n)
Hollis Potter, MD, New York, NY (a – GE Healthcare) John M Murkin, MD, London, Canada
Chitranjan S Ranawat, MD, New York, NY (a – Bayer Healthcare, Inc.)
(e – DePuy, Stryker) Abstract: With increased numbers of THAs, projected shortfalls
Abstract: The evaluation of hip pain following total hip arthro- in blood availability, and heightened awareness of untoward
plasty (THA) is often challenging in the absence of obvious radi- outcomes associated with transfusion, blood management in
ographic pathology. Recent advances in magnetic resonance orthopedics is important. This multicenter, double-blind
imaging (MRI) sequencing have greatly improved its diagnostic placebo controlled study evaluated safety and efficacy of apro-
utility by decreasing metallic artifact. The purpose of this study tinin in reducing blood transfusion in subjects undergoing THA.
was to investigate the use of modified MRI in the diagnosis and Subjects were stratified by preoperative autologous blood dona-
management of wear-induced periprosthetic inflammation and tion and randomized to receive aprotinin (1 mL test dose; 2
osteolysis following THA. Nineteen patients (twenty-one hips) million KIU load; 0.5 million KIU/hour) or placebo until skin
presenting with pain following THA were evaluated with MRI. closure. Subjects were assessed at baseline, postoperative days 1,
Radiographically most had little or no wear, without evidence of 2, 3, 7 (or discharge) and 6±2 weeks. Primary efficacy was the
osteolysis; those with osteolysis had symptoms out of propor- percentage of subjects requiring blood transfusion through day
tion to radiographic findings. MRI findings were utilized in a 7 or discharge. Safety was based on adverse event (AE) profiles.
treatment algorithm of activity modification, NSAIDs, bisphos- Three hundred fifty-two subjects received study medication
phonates, aspiration, or revision surgery. In addition, osteolysis (placebo, 177; aprotinin, 175) and were included in both safety
was quantified on XR and MRI. Pathology was demonstrated in and intent-to-treat analyses. Group demographics were similar.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

all hips, including abductor tendinosis (seventeen), periacetab- Aprotinin reduced the requirement for any transfusion by 46%
ular osteolysis (ten), femoral osteolysis (seven), particle-induced (30/175 vs 56/177 subjects, p=0.0009). Aprotinin reduced allo-
synovitis (seven), iliopsoas bursitis (six), iliopsoas tendinosis geneic transfusion, regardless of predonation status (p<0.05).
(five), scarring of the pseudocapsule (three), trochanteric bursitis Numbers of any (48 vs 109 units; p=0.0003) and allogeneic (30
(two), and soft-tissue ganglia (two). Using these results, fourteen vs 72 units; p=0.0041) units transfused were reduced in the apro-
patients were successfully treated with non-operative manage- tinin group relative to placebo, as was total blood and fluid loss
ment, one had a therapeutic aspiration, and four underwent (709 vs 957 ml; p=0.0002).Serious AEs (placebo 11%; aprotinin
revision surgery. Furthermore, MRI identified much more peri- 10%) and AEs (placebo 86%; aprotinin 83%) showed no clini-
acetabular osteolysis (10,999 mm3 vs. 186 mm2) and femoral cally important differences between the groups. One patient in
osteolysis (1,370 mm3 vs. 269 mm2) than did XR. Recent the placebo group died. Hypersensitivity to aprotinin was not
advances in MRI sequencing have improved its effectiveness in observed. This study demonstrated full-dose aprotinin to be safe
visualizing a wide range of disorders in the periprosthetic tissues and effective in decreasing blood transfusion in THA.
following THA. The diagnostic accuracy of MRI can be used
successfully in a treatment algorithm in patients with enigmatic
pain. POSTERS
POSTER NO. P001
Long-Term Survivorship of Contemporary
Cemented Femoral Components in Young Patients
Young-Hoo Kim, MD, Seoul, Republic of Korea (n)
Jun Shik Kim, MD, Seoul, Republic of Korea (n)
Sung-Hwan Yoon, MD (n)
Abstract: The purpose of this prospective study was to evaluate
the long-term results of the use of the Charnley Elite-Plus
femoral components in young patients. One hundred and
eighty-four patients (194 hips) were included in the study.
Cemented Charnley Elite Plus stem and cementless cup was

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
383
PPSE 07:Layout 1 1/12/07 1:40 PM Page 384

used in all hips. There were 130 men and 54 women. The mean POSTER NO. P003
age was 49.1 years (21 to 60 years). The predominant diagnosis Polyethylene Wear at 9 Years with a Modular
was osteonecrosis of the femoral head (117 patients, 64%).
Clinical and radiographic evaluations were performed preoper- Titanium Acetabular Component with New Locking
atively; at six weeks; at 3, 6, and 12 months; and yearly thereafter. Mechanism
The average duration of follow-up was 11.2 years (10-12 years). John Hubbard, MD, Chapel Hill, NC (*)
The average Harris hip score was 43.4 points preoperatively, Paul F Lachiewicz, MD, Chapel Hill, NC (a, e – Zimmer)
which was improved to 91 points at the final follow-up. One hip
Elizabeth S Soileau, RN, Chapel Hill, NC (*)
(0.5%) had a revision of both components, because of infection.
One femoral component (0.5%) was revised for a loose stem Abstract: The first generation modular titanium-fiber metal
after a femoral fracture. Two acetabular components (1%) were acetabular components were notable for high rates of pelvic
revised for recurrent dislocation. One femoral stem (0.5%) and osteolysis, backside wear and liner dislodgement. This is a
one femoral component (0.5%) had aseptic loosening. Annual prospective, consecutive study of a modular titanium-fiber
wear of the polyethylene liner averaged 0.17 mm. The preva- metal acetabular component with a new polyethylene locking
lence of acetabular osteolysis was 11% (21 hips) and osteolysis mechanism. Of 170 consecutive primary total hip arthroplasties
in calcar femorale was 13% (25 hips). Advancements in performed with this component between 1994-1997, 111 hips
cementing technique and proper positioning of the Charnley had a mean follow-up time of 9 years (range, 7-11 years)by one
Elite-Plus stem have greatly improved the long-term survival of surgeon.All components were implanted with a 1 mm press-fit
the implants in young patients. The high rate of linear wear of and screw fixation. The polyethylene was gamma irradiaed in
polyethylene liner in these high-risk young patients should seek an inert gas.Clinical evaluation was performed with the Harris
the new bearing surfaces. hip score. Radiographs were evaluated for radiolucent lines,
osteolysis and 2-D polyethylene wear. No acetabular compo-
POSTER NO. P002 nent migrated, none were revised and there was no liner
dislodgement. Two liners were exchanged for recurrent disloca-
Comparison of Digital and Acetate Templating for tion and three were exchanged at time of femoral revision.
Preoperative Planning of Primary THA Pelvic osteolysis was seen in only 4 hips (3.6%). The mean
Richard Iorio, MD, Burlington, MA (n) linear wear rate was 0.085 mm/year (range 0.001-0.3). Patients
Jodi Siegel, MD, Boston, MA (n) 50 years or younger had a significantly higher wear rate (0.122
Lawrence Specht, MD, Burlington, MA (n) mm/year) compared to patients>50 years (0.068 mm/year).
The first generation component had 13.7% osteolysis, 15.7%
William L Healy, MD, Burlington, MA (n)
liner exchange and 1 revision for loosening.This is the longest
John F Tilzey, MD, Beverly, MA (n) follow-up of this acetabular compound.We report a high rate of
Abstract: Introduction: Accurate preoperative templating facili- success and low rates of polyethylene wear and pelvic osteolysis
tates precise, efficient, and reproducible THA. The purpose of for this length of follow-up, which may be related to the new
this study was to compare the accuracy of acetate and digital locking mechanism and decreased backside wear of this
templating for primary THA. Methods: Preoperative planning modular acetabular component.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

was performed on 50 consecutive preoperative radiographs

during 2005. Appropriately magnified analog copies of digital POSTER NO. P004
films were printed. Acetate templating was performed by 4
arthroplasty surgeons and one resident. One digitally trained
Effect of Epoetin Alfa on Blood Transfusions During
surgeon also performed digital templating. Templating results Total Knee and Hip Arthroplasty
were compared to the actual hip implants utilized. Inter-rater Michael A Mont, MD, Baltimore, MD
reliability of acetate templating and accuracy of acetate and (e – Stryker Orthopaedics)
digital templating were recorded. Results: Acetate and digital Lynne C Jones, PhD, Baltimore, MD (a – Stryker, Zimmer)
templating both accurately predicted implant utilization. Digital German A Marulanda, MD, Baltimore, MD (n)
measurements significantly over estimated acetabular size
Thorsten M Seyler, MD, Baltimore, MD (n)
(p<.001) and under estimated femoral size (p=.03). The
absolute errors were slightly larger for digital compared to David S Hungerford, MD, Baltimore, MD (c – Stryker)
acetate templating, however, the mean absolute errors did not Abstract: Little experience exists about the use in primary arthro-
differ significantly (acetabulum p=.090, femur p=.114). plasties of cementless conical stems The Cone Stem was
Reliability analysis for absolute agreement of acetate templating designed in the 80’s by Wagner. The stem is made of a rough
demonstated that acetabular sizing as a a single measure [0.70 blasted Titanium Alloy with a cone angle of 5° and 8 sharp
(0.51-0.81)] and as a mean [0.92 (0.83-0.96)] and femoral sizing longitudinal ‘ribs’ that cut into the cortex, providing excellent
as a single measure [0.84 (0.74-0.90)] and as a mean [0.96 rotational stability: The CCD angle is 135°. The stem is straight
(0.93-0.98] were above the prescribed threshold of 0.70. For and can be implanted in any degree of ante- or retro-version thus
consistency, reliabililty analysis of acetabular sizing as a single being indicated in dysplastic arthritis where we need to correct
measure was 0.78 (0.69-0.85) and as a mean was 0.95 (0.92- anteversion. Between 1993 and 1998 the Senior Author (RB) has
0.97). Femoral sizing, as a single measure was 0.87 (0.74-0.90) implanted 92 consecutive cone stems in 88 patients with
and as a mean was 0.97 (0.96-0.98). Conclusion: Digital dysplastic arthritis. The acetabular component was always
templating was determined to be acceptably safe when cementless and in Titanium. The articulating surface was Metal-
compared to the ‘gold standard’ of acetate templating for preop- on-Metal. The average follow-up was 10.1 years.According to the
erative planning of primary THA operations. Good to excellent Hartofilakidis classification we had 63 patients of type A, 18 of
inter-rater reliability was demonstrated for acetate templating. type B and 11 of type C. Clinically we had 89% of Satisfactory
results with no cases of anterior thigh pain.No patient required
revision of the stem, while we revised a cup in Group
C.Radiographically, 17% of patients showed some resorption in

384 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 385

femoral zone 1 and 7. In 12 cases it was a narrow fissure due to patients (3 hips) were lost, and 4 patients (5 hips) had less than
the oscillations of proximal stem under load. This lesion was 2 years F/U. The final analysis included 16 patients (23 hips).
never progressive. In the same zones we observed 4 cases of real Mean F/U was 4.5 years (2-9.5). The mean OR time was 156
osteolysis. No radiolucent line was observed in other femoral minutes,EBL 330ml, and hospital stay 3.8 days. 3 patients died: 1
zones. In the acetabular side we had 13 cases (14%) of radiolu- from AIDS at 10 months, 2 with unknown causes at 52 and 84
cency. Cone stem gave excellent clinico-radiographical results in months respectively. Harris hip score was on average 43 preop,
dysplastic arthritis. and 87 final. Among the un-revised hips, 80% were rated good
or excellent, and 20% fair or poor. All surviving hips were judged
POSTER NO. P005 to have stable fixation. There was no infection, DVT, or disloca-
◆Cobalt and Chromium Ion Levels in Patients with tion. One patient had fever of unknown origin during the
hospital stay. 3 patients (4 hips) underwent revision of one or
a Metal on Metal Hip Resurfacing Prosthesis both components. All were for aseptic loosening at 55 months
Paul R Kim, MD, Ottawa, Canada (48-64). All 4 revised stems were of identical design with matte-
(a, e – Wright Medical Technology) finish inserted with cement. THR is safe and efficacious in this
Michael Dunbar, MD, PhD, Halifax, Canada (a) group of patients. We did not have any infections, perhaps due to
G Yves Laflamme, MD ,FRCS, Montreal, Canada (a) the relatively healthy status of these patients. These were young
Paul E Beaule, MD, Ottawa, Canada (a, e) and active patients. As patients with HIV are being managed with
Anna Conway, MSc (n) improved medical therapy, they are expected to have near normal
life expectancy. It is therefore important to continue to monitor
Heather Hrushowy, BScN (n)
these patients carefully for wear and loosening.
Abstract: Cobalt and chromium ion levels become elevated
following insertion of a metal on metal hip prosthesis. Few POSTER NO. P007
studies have prospectively assessed ion levels following hip
resurfacing arthroplasty. This study was undertaken to evaluate
The Value of Intraoperative Frozen Section in
cobalt and chromium levels following hip resurfacing arthro- Revision Hip Surgery
plasty with a contemporary design implant. Sixty patients who Leandro V Nunez, MD, Buenos Aires, Argentina (n)
underwent metal on metal hip resurfacing arthroplasty were Martin Buttaro, MD, Buenos Aires, Argentina (n)
enrolled in a prospective trial to assess serum, erythrocyte and Rodolfo Pusso, MD (n)
urine cobalt and chromium ion levels. Levels were measured
Francisco Piccaluga, MD, Buenos Aires, Argentina (n)
preoperatively, and postoperatively at 3 months, 6 months then
yearly. Measurements were performed using a high resolution Ana Morandi, MD (n)
ICPMS assay machine. Preoperatively median cobalt and Abstract: The diagnosis of a not evident infected prosthesis is
chromium levels were within the normal range. At one year, frequently difficult, mainly because of the lack of reliable and
median serum cobalt levels were 1.1 ug/l and median serum specific detection methods. Even at surgery it is not easy to assess
chromium levels were 1.9 ug/l. The median levels at two years whether the prosthesis is infected or not in order to decide the
were 1.6 ug/l for cobalt and 3.3 ug/l for chromium. At one year, proper surgical procedure. The purpose of this study is to estab-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

median erythrocyte cobalt levels were 0.8 ug/l and median lish the sensitivity, specificity, predictive value and reliability of
erythrocyte chromium levels were 1.2 ug/l. The median erythro- the results of the analysis of frozen sections from samples of
cyte levels at 2 years were 1.1 ug/l for cobalt and 1.2 ug/l for tissues taken during revision hip surgery. In this survey (from
chromium. Resurfacing arthroplasty is associated with elevated January 1998 to December 2003), 146 probably infected hips in
cobalt and chromium ion levels. These levels did not show a 136 patients were studied. In all of them, samples of tissues were
significant reduction following the ‘wear in period’ for metal on taken to be analyzed immediately on frozen section, to be
metal implants. There is a strong correlation between serum and routinely processed later and to be referred for bacteriological
erythrocyte cobalt levels but a poor correlation between serum cultures. The standard to consider a result as positive was the
and erythrocyte chromium levels. This emphasizes the need for finding of 5 or more polymorphonuclear leukocytes per field at
a standardized method of ion assessment and reporting a magnification of 400X. Statistical comparative analysis
following any metal on metal hip arthroplasty. between the findings on the frozen sections and the results of the
routine sections showed a sensitivity of 98%, specificity of 99%,
POSTER NO. P006 a positive predictive value of 98%, a negative predictive value of
99% and a correlation of nearly 0.99. When comparing with the
Total Hip Arthroplasty in HIV Infected Patients results of the cultures showed a sensitivity of 85%, a specificity
John McGarry, MD, Dallas, TX (n) of 88%, a PPV of 81%, a NPV of 91% and an accuracy of 87%.
Michael H Huo, MD, Dallas, TX (n) Arising out this work, we believe that the tested method can be
Abstract: Osteonecrosis (ON) of the femoral head has been used in revision surgery as a routine when a certainty of a diag-
recognized as a distinct entity in patients infected with HIV. The nosis is essential. We have to emphasize that the cooperation of
incidence has been reported to be 0.3% to 0.5%. The purpose of a well-trained pathologist is essential.
this study was to evaluate the clinical and radiographic outcome
in a consecutive series of primary THRs performed for ON in HIV
patients 23 patients underwent 31 THRs under one single
surgeon over an 8-year period. All patients were male. All
contracted HIV through sexual contact. Risk factors for ON
included: protease inhibitors in 74%, hypercholesterolemia in
21.7%, alcohol abuse in 13%, and steroid use in 8.7%. Ficat class
included: II (10%), III (45%), IV (45%). The mean age was 42
years (29-65). The mean BMI was 24 (18-29). The mean CD4
count was 377 (14-900), and viral load was 70 (0-126k). 3

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
385
PPSE 07:Layout 1 1/12/07 1:40 PM Page 386

POSTER NO. P008 survival was 73% at five years. Allograft-prosthesis needed to be
Effects of Femoral Head Size on Serum Cobalt and removed in nine patients due to 3 infections and 6 fractures. All
fractures occurred in the group not adequately protected with
Chromium Levels Following Hip Resurfacing the internal fixation, this difference was statistically significant
D Gordon Allan, MD, Springfield, IL (b – Corin U.S.A.) (p<0.05). Eight patients in which the host greater trochanter was
Brad Dyrstad, BS (n) reattached performed a nonunion. No patient with a tendon-to-
Joseph C Milbrandt, PhD (n) tendon repair suffers a disruption of the abductor function.
Abstract: Metal-on-metal (MOM) hip resurfacing devices are None of these patients treated with composite reconstructions
known to release metal ions locally and into the systemic circu- suffered a dislocation Allograft survival at five years was 73% in
lation. Previous studies suggest that larger prosthetic head size this series. Fractures were related with areas of the allograft that
will correlate to reduced wear properties and may result in lower were not adequately protected with internal fixation. The plate
systemic release of metal ions. This project assessed the effect of should expand the entire length of the allograft to minimize the
femoral head size on serum cobalt (Co) and chromium (Cr) risk of fracture. Tendon-to-tendon repair is recommended and
levels in subjects after unilateral hip resurfacing with the Cormet provides solid healing.
2000 prosthesis. We prospectively collected patient characteris-
tics, outcome, and serum samples from device implanted
POSTER NO. P010
subjects at 6 months, 1, 2, and 3 years following surgery. Serum Management of the Retroverted Acetabulum:
Co/Cr levels were determined using high-resolution inductively Hip Preserving Surgical Options
coupled plasma mass spectrometry. Students t-test was used to
Christopher L Peters, MD, Salt Lake City, UT (n)
compare ion levels in two groups based on femoral head size
(less than 48mm and equal to or greater than 48mm). Jill Erickson, PA, Salt Lake City, UT (n)
Spearman correlation was used to examine correlations between Abstract: The optimum treatment for the young adult patient
ion levels and patient characteristics. We prospectively collected with femoro-acetabular impingement (FAI) due predominately
patient characteristics, outcome, and serum samples from device to acetabular retroversion is currently unknown. Anteversion-
implanted subjects at 6 months, 1, 2, and 3 years following producing periacetabular osteotomy (PAO) with or without
surgery. Serum Co/Cr levels were determined using high-resolu- femoral head-neck osteochondroplasty and surgical dislocation
tion inductively coupled plasma mass spectrometry. Students t- and debridement (SDD) of the femoral head-neck junction and
test was used to compare ion levels in two groups based on the anterior acetabular rim have been utilized without clear
femoral head size (less than 48mm and equal to or greater than evidence of superiority. We have utilized both of these treat-
48mm). Spearman correlation was used to examine correlations ments in patients with acetabular retroversion and present our
between ion levels and patient characteristics. 35 subjects (20 clinical experience. Thirty-eight patients (43 hips, 5 bilateral)
male) were followed. Co/Cr levels were increased at all time had preoperative acetabular retroversion and clinically signifi-
points when compared to control levels. A significant negative cant FAI diagnosed with exam, plain radiographs, MR-arthrog-
correlation was observed between Co and Cr levels and femoral raphy and 3D CT-arthrography. Twenty-eight PAOs and fifteen
head size. Co/Cr levels in subjects with larger femoral heads were SDDs were performed in these patients. The decision to perform
PAO rather than SDD was based on the preoperative condition
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

significantly lower when compared to those implanted with

smaller heads (Co, -35.8 percent; Cr, -33.0 percent). Elevated of the articular cartilage. In the five patients with bilateral retro-
serum Co/Cr levels were observed at all time points following version, four had staged PAOs, one patient had staged SDDs. The
implantation and in subjects with femoral heads less than average follow-up was 38 months. The average age was 26 years
48mm when compared to those receiving larger components. (range 15-44). The average height was 67 inches, average weight
Based on these findings, optimization and utilization of a larger was 160 pounds. Mean Harris Hip score improved from 52 to 90
head should be considered and is warranted in light of concern for the PAO group and 72 to 91 for the SDD group. There was
over elevated trace metals following MOM resurfacing. one failure with infection followed by conversion to total hip in
one patient with spastic cerebral palsy from the PAO group.
POSTER NO. P009 There was one failure requiring conversion to total hip due to
severe articular cartilage delamination from the SDD group.
Outcome of Proximal Femur Allograft-Prosthesis There were no other major complications. Our rationale of
Composite Reconstruction treating acetabular retroversion in younger patients with intact
Miguel Angel Ayerza, MD, Buenos Aires, Argentina (n) articular cartilage with PAO, and patients with evidence of
German Luis Farfalli, MD, Cordoba, Argentina (n) compromised articular cartilage with SDD appears sound, based
Sebastian Bettera, MD, Buenos Aires, Argentina (n) on the low rate of failure and improved clinical outcomes in
Eduardo Abalo, MD, Buenos Aires, Argentina (n) these patients. The decision regarding the best surgical manage-
ment of the retroverted acetabulum remains difficult and
Louis Alberto Aponte-Tinao, MD, Buenos Aires, Argentina (n)
depends on a thorough consideration of hip morphology and
Domingo Luis Muscolo, MD, Buenos Aires, Argentina (n) degree of articular cartilage damage.
Abstract: The purpose of this study was to evaluate survivorship
and complications of proximal femur allograft-prosthesis
composite. We performed a survivorship analysis for 38 prox-
imal femur allograft-prosthesis composites with a mean follow-
up of 7 years. Allograft-prosthesis survival was determined with
Kaplan-Meier method. In twenty-five patients the internal fixa-
tion spanned the entire length of the allograft while in eleven
did not. In 10 patients the host greater trochanter was reattached
to the allograft with screws and wires while in twenty-eight the
host tendons were reattached to the tendinous insertion of the
allograft. Complications were recorded and analyzed. Allograft

386 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 387

POSTER NO. P011 were inside the desired range of inclination and anteversion. The
The Utility and Precision of Analog and Digital difference between the registered values at surgery and the
analyzed ones from post-operative CT data shows the inaccuracy
Preoperative Planning for Total Hip Arthroplasty of the registration. Navigation is less accurate in the lateral than
Alejandro M Gonzalez Della Valle, MD, New York, NY (n) in the supine position because one of the ASISs and the symph-
Fernando Martin Comba, Buenos Aires, Argentina (n) ysis pubis can’t be registered. Newer software for more accurate
Nicole Taveras, BS (n) lateral registration is needed.
Eduardo Agustin Salvati, MD, New York, NY (n)
POSTER NO. P013
Abstract: The standardized printed films required for preopera-
tive templating are being replaced by digital images that can be The Agreement and Repeatability of Computer-
displayed in a PACS monitor. Several preoperative planning soft- Based Wear Measurement of Total Hip
ware packages have been developed. Digital preoperative plan-
ning should be as useful and precise as the traditional method
Arthroplasties
of acetate templates superimposed on standardized radiographs. Alejandro M Gonzalez Della Valle, MD, New York, NY (n)
We prospectively compared the utility and precision of preoper- Fernando Martin Comba, Buenos Aires, Argentina (n)
ative templating performed in printed films (analog) with that Robert Ellis, BS (n)
performed on digital radiographs (digital) in 69 patients under- Margaret G E Peterson, PhD, New York, NY (n)
going primary total hip replacement. Standardized printed and Eduardo Agustin Salvati, MD, New York, NY (n)
digital radiographs with a 100-millimeter magnification marker Abstract: Wear measuring tools have to be precise and repro-
were used, together with 20%-magnified acetate templates for ducible. We assessed the intra- and inter-observer agreement and
the analog plan, and the Impax 5.0 preoperative planning soft- repeatability of the Hip Suite software package for wear meas-
ware package for the digital plan. Two surgeons utilizing similar urement in 19 primary total hip arthroplasties followed for 4 to
surgical approach, technique and implants participated in the 8 years. Three observers with different levels of expertise were
study. 5 patients were excluded as misplacement of the marker selected: a hip surgeon [O1], a fully trained hip arthroplasty
resulted in a magnification error greater that 10%. In the fellow [O2], and a research assistant of the laboratory in which
remaining patients (64 hips), the cup size was within ± one size the software was developed [O3]. Before the study, O3 who had
in 62 (97%) of the analog plans, and in 52 (81%) of the digital extensively utilized the software, trained O2 and O3, until all
(p=0.01). The stem size was within ± one size in 63 (98%) of the three considered that they were proficient in the use of the soft-
analog plans, and 60 (94%) of the digital (p=0.39). The distance ware. Thus, the first two observers represent the average hip
from the proximal corner of the lesser trochanter to the pros- surgeon and hip fellow utilizing the software for clinical and
thetic head (LTCD) in the analog plan had a difference of 5 academic purposes. The observers determined in two non-super-
millimeters or more from the digital one in 9 cases (14%). vised reading rounds the two-dimensional wear. For intra- and
Analog preoperative planning yielded more predictable results inter-observer comparisons we utilized intraclass correlation
than the digital one, particularly in acetabular component size; coefficient (ICC) and repeatability. . The intra-observer ICC for
and LTCD that dictates limb lengthening-shortening. The wear and wear direction was 0.83 and 0.78 for O1, 0.54 and 0.48

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

sources of error were not clearly explained by variations in for O2, and 0.81 and 0.89 for 03. The intra-observer ICC coeffi-
magnification. Inconsistent positioning of the magnification cients indicated fair or good reproducibility. The inter-observer
marker may jeopardize safe implementation of digital ICCs was 0.43 (range 0.07 to 0.87) for wear (fair agreement) and
templating. 0.8 (range 0.71 to 0.86) for wear direction. The repeatability
coefficient for intra-observer comparison averaged 0.19 mm (47
POSTER NO. P012 times higher than the ones reported by the proponents of the
Accuracy of Cup Position of THA Through a Mini- technique), and for inter-observer comparison was 0.277 mm
Posterior Approach Using CT-Based Navigation (4.5 times higher). Our study demonstrated that computerized
wear measurements have substantial intra- and inter-observer
Motomi Ishibe, MD, Sapporo, Japan (n)
variability, especially when performed by orthopaedic surgeons
Masayuki Inoue, MD, Sapporo, Japan (n) without extensive experience in the use of the software, a finding
Abstract: Computer-assisted navigation compensates for the which questions its precision and validity.
decreased visualization, the disadvantage of the posterior mini-
incision THA reducing the risk of cup malposition. The aim of POSTER NO. P014
this prospective study is to evaluate its accuracy. 65 hips replaced
(average age: 59 years) by mini-posterior approach (average inci-
Intra-articular Hip Pathology: Correlation Between
sion: 7 cm) using the CT based computer navigation system, MR-Arthrography and Direct Visualization
VectorVision Hip 2.5.1 from BrainLAB were examined. Christopher L Peters, MD, Salt Lake City, UT (n)
Registration was performed following the manual in the same Lucas Anderson, PA (n)
lateral position as the surgery. The goal was 35 to 45 degrees of Brandon Park, MS (n)
operative inclination and 20 to 30 degrees of anteversion.’All Julia Crim, MD (n)
cups were DePuy Duraloc 1200 averaging 50 mm. The cup posi-
Abstract: Several studies have correlated magnetic resonance
tion was analyzed a week post-operatively from CT data using
arthrography (MRA) with hip arthroscopy, but few have assessed
VectorVision Hip. The navigated values registered at surgery were
hip pathology by open surgical technique. Our study compared
41.3 s.d. 4.2 degrees of inclination and 24.7 s.d. 5.5 degrees of
findings of MRA with open arthrotomy for intra-articular
anteversion. The values from post-operative CT data were 38.1
pathology including labral and articular cartilage damage. We
s.d. 5.4 degrees of inclination and 21.6 s.d. 8.0 degrees of antev-
retrospectively collected MRA studies and operative reports from
ersion. The difference between the values at surgery and post-
surgical dislocation and debridements and peri-acetabular
operation in each case was 3.2 s.d. 6.5 degrees of inclination and
osteotomies on 29 hips (27 patients) from 2001-2006. Surgical
3.1 s.d.7.3 degrees of anteversion. 74% and 51%, respectively,

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
387
PPSE 07:Layout 1 1/12/07 1:40 PM Page 388

findings were correlated with initial MRA reports as well as a POSTER NO. P016
blind reassessment by a musculoskeletal radiologist. MRA Extended Warfarin Prophylaxis Prevents Venous
assessments that did not correlate with operative findings were
subjected to an unblinded conspicuity assessment. Error analysis Thromboembolism Readmission after THA and TKA
was used to improve diagnostic criteria. At surgery, a total of 20 Vincent D Pellegrini Jr, MD, Baltimore, MD (n)
labral lesions and 20 articular cartilage lesions were identified. Christopher T Donaldson, MD, Baltimore, MD (n)
Sensitivities and specificities for labral pathology were 79 and Daniel C Farber, MD, Mount Airy, MD (n)
40%, 45 and 67% for acetabular articular cartilage lesions, 100 Erik B Lehman, MS, Hershey, PA (n)
and 33% for femoral articular cartilage lesions, and 11 and 75% C Mc Collister Evarts, MD, Rochester, NY (n)
for acetabular delamination. On unblinded read, 80% of discor-
Abstract: Venous thromboembolism (VTE) remains the most
dances were found conspicuous. MRA was sensitive and specific
common reason for hospital readmission and death after total
for labral pathology. Articular cartilage pathology on the femoral
hip (THA) and knee (TKA) arthroplasty. Screening contrast
head and acetabulum was not well predicted by MRA. Error
venography was performed in 3293 patients after 1972 THA and
analysis showed good correlation with findings, demonstrating
1321 TKA; those with a negative study received no further anti-
that experience and revised diagnostic criteria improves accuracy.
coagulation after discharge. Patients with VTE received warfarin
We believe continued efforts at correlating operative findings
for 6 (calf DVT), 12 (thigh DVT), or 24 (PE) weeks. From 1984-
with MRA will lead to improved diagnostic accuracy and preop-
1992, patients without venography were discharged without
erative planning.
further anticoagulation; from 1993-2003, they received 6 weeks
POSTER NO. P015 warfarin. Six month postoperative audit noted readmission for
DVT, PE, and bleeding. Of 1842 venograms, DVT was evident
Implant Position in LIS Hip Surgery Showed after 17% THA (175/1032) and 42.3% TKA (343/810). Epidural
Reduced Variability When Using Surgical anesthesia reduced DVT prevalence only after THA (14.2% vs.
Navigation 22.5%; p=0.0008). Readmission for VTE occurred after 1.62%
THA (32/1972; 14 PE, 18 DVT) compared with 0.6% TKA
Joseph P Nessler, MD, Saint Cloud, MN (8/1321; 3 PE, 5 DVT; p=0.009). On outpatient warfarin, read-
(a, e – Stryker Orthopedics) mission occurred after 0.28% THA (1/360) and 0.21% TKA
Cindy L Mendel, Saint Cloud, MN (n) (1/484) compared with 2.2% THA (19/880; p=0.013) and
Gerald B Nelson, OPA-C, Saint Cloud, MN (n) 1.05% TKA (5/477; p=0.12) with negative venography and no
Abstract: Less invasive techniques for hip replacement have further anticoagulation. Extended warfarin eliminated
become increasingly popular, but concerns persist regarding the pulmonary embolism (0/844 vs. 17/2449; p=0.01) and reduced
ability to accurately place components through limited inci- readmission (2/844 vs. 38/2449; p=0.0015). Four patients (3
sions. This study evaluated the ability of a surgical navigation THA, 1 TKA; negative venography, no outpatient warfarin)
system to improve component positioning. Twenty patients suffered fatal pulmonary embolism. One fatal intracranial bleed
were prospectively evaluated to assess cup position in dual inci- occurred on warfarin. Even surveillance venography poorly
sion hip replacement performed using a surgical navigation predictors need for VTE prophylaxis after discharge following
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

system. The results were compared to a similar group of twenty total joint arthroplasty. Extended outpatient low intensity (INR
patients who received dual incision hip replacement without 1.5-2.0) warfarin safely reduces clinical pulmonary embolism
surgical navigation. All patients were evaluated with post-opera- (P=0.01) and readmission for VTE (P=0.0015) compared with
tive CT scans of the pelvis to assess acetabular inclination and no anticoagulation after discharge following THA and TKA.
anteversion angles. The computerized tomographic images were
measured in the true axial and coronal planes of the pelvis, as POSTER NO. P017
defined by the most prominent aspect of the 2 anterior superior Different Outcomes with Two New Polyethylenes in
iliac spines and the most prominent aspect of the pubic symph-
ysis. Results showed significantly lower variability in cup incli-
Total Hip Replacement: A Prospective Study
nation angles in the group utilizing surgical navigation (p<0.02). Eduardo Garcia-Rey, MD, Madrid, Spain (n)
The anteversion angles showed greater variability than inclina- Eduardo Garcia-Cimbrelo, MD, Madrid, Spain (n)
tion in both groups. There was a trend toward less variability of Ana Cruz Pardos, Madrid, Spain (n)
anteversion in the navigated group (p=0.10). There was a strong Pablo Diaz Freiere, MD, Madrid, Spain (n)
correlation between the position of inclination and anteversion Abstract: Polyethylene (PE) sterilized in absence of air and
as indicated intra-operatively by navigation, and the true incli- highly cross-linked polyethylene (HXLPE) have been used to
nation and anteversion as measured by CT scan. This study of a avoid osteolysis and loosening. This prospective randomized
single surgeon’s experience comparing navigated and non-navi- study has assessed results of a series using two different polyeth-
gated hip replacements in dual incision arthroplasty demon- ylenes associated with the same prosthetic design We assessed 45
strates the ability of navigation to improve surgical accuracy and Allofit cups with Sulene-PE liner (sterilized with nitrogen) and
reduce variability in cup placement. Navigation should allow 45 Allofit cups with Durasul-PE liner (HXLPE) associated with
surgeons to continue to develop and improve on less invasive or an Alloclassic stem (28-mm femoral head) (Zimmer) and a 5-
muscle sparing techniques in hip replacement while not year minimum follow-up (mean follow-up was 66.3 months).
compromising component position. The linear femoral head penetration was estimated at 6 weeks, at
6 and 12 months and annually thereafter, using the Dorr
method, given the nonspherical cup shape, using a software
package All assessed hips had good clinical and radiographic
results. There was no loosening of any prosthetic component.
There were no radiolucent lines or osteolysis. Femoral head
penetration in the early postoperative radiographs was 47.4%
less in the Durasul group (0.19+0.06 mm for the Sulene-PE

388 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 389

group and 0.09+0.03 for the Durasul-HXLPE [p<0.0001]). The POSTER NO. P019
mean yearly linear femoral head penetration was 20% lower in Randomized Study of Gait Analysis after Total Hip
the Durasul group (0.04+0.02 and 0.008+0.008 [p<0.0001]
respectively). Differences increase after the third year. Mean Resurfacing and Total Hip Arthroplasty
linear femoral head penetration at 5 years was 39.1% less in the Pascal-Andre Vendittoli, MD, Montreal, Canada
Durasul group (p<0.0001) There is a significant reduction in (a, e – Zimmer, Smith and Nephew, a – Stryker)
yearly linear femoral head penetration with Durasul-HXLPE in a Martin Lavigne, MD, Montreal, Canada
5 - year minimun follow-up. Longer-term results are needed to (a, e – Zimmer, a – Stryker, Smith and Nephew)
confirm that these data Julie Nantel, MSc (a – Zimmer)
POSTER NO. P018 Alain Roy, MD, Montreal, Canada
(a, e – Zimmer, a – Stryker, Smith and Nephew)
Metal Ion Release Following Metal-on-Metal 28mm Francois Prince, PhD (a – Zimmer)
Total Hip and Surface Replacement Arthroplasty Abstract: Biomechanical studies have shown that patients with a
Pascal-Andre Vendittoli, MD, Montreal, Canada total hip arthroplasty (THA) walk with different gait kinematic
(a, e – Zimmer, Smith and Nephew, a – Stryker) and kinetic pattern compared to normal subjects. This different
Martin Lavigne, MD, Montreal, Canada gait pattern might result from difficulties restoring the normal
(a, e – Zimmer, a – Stryker, Smith and Nephew) hip anatomy and biomechanics with THA. Surface replacement
Sophie Mottard, MD, Saint Lambert, Canada arthroplasty (SRA) facilitates leg length management and recon-
struction of the normal anatomy of the proximal femur,
(a – Zimmer, Stryker, Smith and Nephew)
allowing potential improvements in gait parameters compared
Alain Roy, MD, Montreal, Canada to THA. Twenty patients suffering of advanced hip joint disease
(a, e – Zimmer, a – Stryker, Smith and Nephew) were randomized to receive an uncemented metal-metal THA or
Abstract: Improved factors influencing component wear with metal-metal SRA. Biomechanical analyses were performed in a
regards to bearing surfaces, metallurgy, tribology, and manufac- gait laboratory pre-operatively and six months post-operatively.
turing technology allowed reintroduction of metal-on-metal An 8-camera VICON system and two AMTI force platforms were
(MOM) articulation in total hip arthroplasty (THA) and surface used to quantify temporal measures (gait velocity, cadence and
replacement arthroplasty (SRA). One hundred and twenty four stride length) and kinetics parameters (power and work) at the
hips were randomised to receive an uncemented, titanium THA hip, knee and ankle during a straight line locomotor task at
with 28mm MOM articulation (CLS/Allofit/Metasul, Zimmer, natural cadence. A significant increase in gait velocity was found
USA) or MOM SRA (Durom, Zimmer, Warsaw). Both compo- post-operatively in both SRA and THA due to an increase of
nent systems included forged, high carbon content chrome- cadence and stride length. However, no significant differences
cobalt bearing surfaces. Samples of whole blood, serum and were found between THA and SRA in temporal and stride meas-
erythrocytes were collected pre-operatively and post-operatively ures during both pre- and post surgery. Similarly, no statistical
at three months, six months, one year and two years. Chromium differences were reported for kinetic measures between THA and
and cobalt concentrations were measured using a high-resolu- SRA, but significant modifications in kinetic pattern were

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

tion, sector-field, inductively-coupled plasma mass spectropho- observed six months after surgery for both prostheses. Our
tometer (HR-SF-ICP-MS). At one year, whole blood metal ions results showed no significant gait differences between THA and
levels were: Cr 1.55 umol/L (SD 0.91, min 0.4, max 4.5) and Cr SRA, suggesting similar impacts on gait patterns for both pros-
1.62 umol/L (SD 0.73, min 0.4, max 3.2) and Co 0.65 umol/L thesis six months after surgery. However, surgery led to greater
(SD 0.33, min 0.23, max 2.09) and Co 0.88 umol/L (SD 0.48, gait velocities, mainly due to greater power generations by the
min 0.23, max 2.30) for the SRA and THA respectively (Cr ankle plantar flexors. The gait velocities were also increased
p=0.690; Co p=0.01). In comparison to the pre-operative levels, because of the reduction of power absorption by the knee exten-
post-operative whole blood metal ion levels increased signifi- sors (K3) that allowed greater stride lengths.
cantly for all elements Cr 1.5x, Co 5.2x for the SRA group, and
Cr 1.6x, Co 5.5x for the THA group. A significant difference was POSTER NO. P020
found between whole blood, serum and erythrocytes concentra- Reduced Hip Muscle Density, Mass and Strength in
tions of Cr (p=0.001) and Co (p<0.001). Pearson’s correlation
coefficients between the three mediums were over 0.92. For Cr OA Patients Undergoing THA
and Co, the average ratios of serum and erythrocytes over whole Hans Berg, Danderyd, Stockholm, Sweden (n)
blood were respectively 1.3 and 0.8. The chromium and cobalt Anton Rasch, MD, Stockholm, Sweden (n)
levels found in the THA and SRA groups are comparable to the Nils Dalen, MD, PhD, Danderya, Sweden (n)
best published results with 28mm MOM articulations. The data Abstract: Abductor muscle weakness and painful limp are recog-
spread (SD) and the proportions of outliers in the two groups nized impairments in hip osteoarthritis (OA). Still, quantitative
were very small. Comparing the two groups, the cobalt level of hip and knee muscle data pre and post THA are lacking. We
the tested SRA implant was lower than the THA. The results of hypothesized that the reduced activity in OA results in severe
this study are in accordance with the concepts of reduced wear strength loss and muscle atrophy in multiple lower limb muscles.
with larger diameter MOM articulations. Our purpose was therefore to map out muscle mass and strength
in unilateral OA patients undergoing THA. Isometric hip and
knee muscle force was measured in 20 elderly patients before
THA and after 6 months of rehabilitation. Computerized tomog-
raphy was used to measure both cross-sectional area (CSA) and
radiological density (RD) of hip and knee muscles. Clinical
scores (EQ-5D, SF-36, HHS) were collected. Hip extension,
flexion, abduction and adduction, and knee extension strength

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
389
PPSE 07:Layout 1 1/12/07 1:40 PM Page 390

was reduced (10-30 per cent) in the OA relative to healthy limb. late clinical presentation with size and location of embolus
Muscle CSA of hip extensors, flexors and adductors, and knee within the pulmonary vasculature. The clinical and imaging
extensors and flexors was reduced (10-15 per cent) in the OA records of all patients with confirmed diagnosis of PE following
limb, where RD of muscles was reduced (5-15 Hounsfield units). TJA performed between 2000 and 2005 were reviewed in detail.
Six months after THA, deficits were not recovered, whereas clin- The mode of presentation and the subsequent imaging findings
ical scores improved. The substantial loss in strength and mass is were noted. PE cases were then subdivided by size and location
likely to reduce the ambulatory capacity of OA patients. Strength based on radiography. For size, each PE was categorized as: small,
loss was not fully explained by the decreased muscle CSA. Fat medium, or large; and for location the categories were: main-
infiltration, as indicated by a decreased RD, partially masked the stem, lobar, segmental, and subsegmental. Data on presenting
net loss of muscle protein. The recovery of muscle mass and func- signs and symptoms, changes in vital signs, as well as arterial
tion after THA is modest and future studies should evaluate if blood gases was similarly tabulated for each subgroup 14,890
soft-tissue sparing surgery or enhanced rehab might improve the cases of hip and knee arthroplasty were reviewed, and 144
restoration of muscle after THA. confirmed PE’s were identified and studied. The presenting
symptoms were: Shortness of breath (31.9%), mental status
POSTER NO. P021 change (27.1%), chest pain (12.5%), diaphoresis (9.7%),
Prevalence of Instability in Septic Revision THA hemoptysis (2.8%) and no presenting symptoms in 32.6 % of
the patients. The most common presenting signs were:
Thomas K Fehring, MD, Charlotte, NC (a, c, e, – DePuy)
Hypotension (30.6%), tachycardia (28.5%), fever (20.8%) and
Stephen G Struble, MD, Richmond, VA (a – DePuy) tachypnea (18.8%). At the time of presentation, 35.4% of
Susan Marie Odum, MED, Charlotte, NC (a – DePuy) patients had normal vital signs and 9.7% were completely
William L Griffin, MD, Charlotte, NC (a, b, c, e – DePuy) asymptomatic. The mean presenting room air pulse oximetry of
Bryan Donald Springer, MD, Charlotte, NC (a – DePuy) PE for all patients in this study was 85.7%. Mean arterial 02 satu-
J Bohannon Mason, MD, Charlotte, NC (a, e – DePuy) ration was 88.2%, and mean PaO2 was 59.0. There was no corre-
Abstract: Hip instability is a common postoperative complication lation between the size and the location subgroups of pulmonary
that is disturbing to surgeon and patient alike. The prevalence of embolism with the clinical presentation. The presentation of PE
dislocation in aseptic revision THA exceeds that of primary can be non-specific and highly variable ranging from mild
surgery. The increased dissection required in revision surgery is a dyspnea to catastrophic hemodynamic collapse. Common clin-
significant contributing factor in this difference. Two-stage reim- ical signs and symptoms, as well as changes in vital signs have a
plantation with its concomitant shortening of the limb requires low sensitivity for diagnosis and do not correlate with severity of
even more extensive dissection. We have noted an increased disease as determined radiographically. Although blood gas
prevalence of postoperative instability following two-stage reim- studies demonstrated a significant decrease in O2 saturation and
plantation despite appropriately placed components. The PaO2 with PE, the degree of arterial desaturation did not corre-
purpose of this study was to define the prevalence of postopera- late with size or location of embolus. Thresholds for the diag-
tive hip instability following two-stage reimplantation and to nosis of clinically significant pulmonary embolisms need to be
develop strategies to minimize this risk. A joint registry review of established to improve management of this important condition.
1515 revision THA identified 134 patients who underwent two-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

stage reimplantation. The prevalence of dislocation was docu- POSTER NO. P023
mented. Femoral head size was documented. A radiographic rhBMP2 and Pamidronate in Experimental
analysis of acetabular component position was also performed. Allografted Gap Implants - Catastrophic Results
Of the 134 patients that underwent two-stage reimplantation,
17.7% dislocated. 77% had 28 mm. heads used, 3% had smaller Jorgen Baas, MD, Aarhus, Denmark
heads used while 20% had larger head sizes used. The average (a – Danfoss, Ossacur, DePuy)
abduction angle for the patients who dislocated was 43° (range Brian Elmengaard, MD, Aarhus, Denmark (n)
38-49). 45% of patients who dislocated required re-revision to Thomas Bo Jensen, MD, PhD, Aarhus, Denmark (n)
obtain stability. This instability rate following two-stage reim- Thomas Jakobsen, MD, Aarhus, Denmark (n)
plantation is clearly unacceptable. Strategies to minimize this Niels T Andersen, PhD, Aarhus C, Denmark (n)
complication must be undertaken. The routine use of postopera- Kjeld Soballe, MD, Aarhus, Denmark (n)
tive bracing, the use of an articulating spacer to maintain length
Abstract: We hypothesized that topical bisphosphonate
between stages or the use of large head technology are treatment
(Pamidronate, Mayne Pharma) in combination with rhBMP2
methods that should be considered in this group of patients.
(InductOs, Wyeth) would give increased mechanical implant
fixation and increased new bone formation without excessive
POSTER NO. P022
allograft resorption. We looked at both porous-coated Ti
Pulmonary Embolus after Total Joint Arthroplasty: implants and HA-coated implants. Four 2.5 mm gap implants
Does Size and Location Matter? were inserted into the proximal humeri of each of 16 dogs. Half
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) the dogs received Ti-implants, the other half HA-implants. The
gap around each implant was impacted with fresh frozen allo-
Eric Smith, MD, Merion Station, PA (n)
graft with/without treatment: 1) control, 2) rhBMP2, 3)
Seth Grossman, BS, Philadelphia, PA (n) pamidronate, 4) rhBMP2+pamidronate. Four weeks observa-
Luis Pulido, MD, Philadelphia, PA (n) tiontime. Superior mechanical fixation was seen for the control
Richard H Rothman, MD, Philadelphia, PA (e – Stryker) groups. The rhBMP2 group had more new bone and less fibrous
Abstract: Pulmonary embolism (PE) is a potentially fatal compli- tissue than the mechanically superior control group. However,
cation of total joint arthroplasty (TJA). Therefore, reliable means there was almost no allograft left in the rhBMP2 group due to
for diagnosis and evaluation of severity is essential. This study extreme resorption.The addition of pamidronate seemingly
evaluates the reliability of common clinical signs and symptoms blocked bone metabolism completely. No new bone was
in the diagnosis of PE. In addition, attempts were made to corre- formed, allograft was preserved, and a dense fibrous capsule

390 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 391

covered the implant surface. The experiment confirms previous up. Mean age 63 years. Structural allograft was used in 7 and
reports of mechanical instability of implants when BMPs are morcellised allograft in virtually all. Graft maturation and
added to periimplanteric defects. Pamidronate alone had cata- consolidation was seen in 80 percent. One third show filling in
strophic effects on bone metabolism and implant fixation in this of small bone defects. There was no significant difference in radi-
experiment. The results encourage extreme caution in adjuvant ographic outcomes between the greater than and less than 50
therapies of arthroplastic surgery. percent host bone contact groups. Oxford and Harris Hip Scores
improved at 1 year post operation. 2 migrated cups occurred
POSTER NO. P024 with 30 percent and 25 percent bleeding host bone contact. This
Risk Factors for Metallosis study shows good early results. Filling in of post operative lucen-
cies may imply construct stability and biologic fixation. It is
Jiri Gallo, MD, Olomouc, Czech Republic (n)
possible to obtain durable biologic fixation with less than 50
Vitezslav Havranek, RN, MSN (n) percent host bone contact
Jana Zapletalova, PhD (n)
Ivana Cechova, MD (n) POSTER NO. P026
Abstract: Metallosis is related to accelerated wear of polyethylene MIS Total Hip Arthroplasty: A Comparison of the
(PE) liners. In addition, the occurrence of metal particles may
increase the size of bone defects around total hip arthroplasty. Two Incision Mini and G3 Approaches
155 retrieved ABG 1 prostheses were analyzed. There were 44 Catherine Kellett, FRCS (Tr & orth)/Dr, Toronto, Canada
men and 111 women with an average age of 52 years at the time (n)
of revision. Design features include hydroxyapatite coating, matte Oleg Safir, MD, Toronto, Canada (n)
inner surface to the shell and PE sterilized by gamma irradiation Robert Korley, MD, Calgary, Canada (n)
in air. Twenty-one of them were revised due to metallosis, the Vikrant Kumar Bubbar, MD, Victoria, Canada (n)
others due to osteolysis or aseptic loosening. The average time
David Backstein, MD, Toronto, Canada (e – Zimmer)
from index surgery to revision was 72 months. PE wear measure-
Allan E Gross, MD, FRCSC, Toronto, Canada (e – Zimmer)
ments were performed using a Universal-type measuring micro-
scope. The average linear and volumetric wear rates were 0.415 Abstract: We compared the learning curve of two Minimally
mm per year (0-2.284, SD 0.364) and 153 cubic mm per year (0- Invasive Surgery (MIS) Total Hip Arthroplasty (THA) approaches:
815, SD 134.4), respectively. A relationship between metallosis the Two-Incision Mini and a modified Watson Jones G3
and several variables was determined by logistic regression approach The first 25 patients on the learning curve for the Two-
analysis. The most important predictors of metallosis were (a) a Incision Mini and the G3 MIS approaches for THA were
men gender (OR=0.106, 95% CI 0.014-0.815), (b) an increased compared. Note was made of BMI, surgical time, incision length,
size of the original cup (OR=0.569, 95% CI 0.426-0.760), and (c) blood loss, component positioning, hospital stay and peri-oper-
hooded polyethylene liners (OR=0.115, 95% CI 0.014-0.950). ative complications. Average acetabular inclination was 37
The other variables were not considered risky or protective for degrees for the G3 and 42 degrees for the Two-Incision Mini. On
metallosis including the age, BMI or abduction angle. ABG 1 average, the femoral component was positioned in neutral in the
implants demonstrated much higher wear rate than reported coronal plane for both approaches. Average surgical time was 121

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

previously resulting in some cases of wear-through. The women minutes for the G3 and 166 minutes for the Two-Incision Mini
with small cups and a standard PE liner constituted the highest- which also includes fluoroscopy time. Hospital stay averaged 5.4
risk group. It is strongly recommend that the patients with such and 6.8 days respectively. The skin incision averaged 8.9 cm for
prosthesis be closely followed-up. G3 and a total of 9.8cm for the Two-Incision Mini. Peri-operative
complications for the G3 were 1 lateral femoral cutaneous nerve
POSTER NO. P025 palsy, 1 DVT, 1 PE and 1 undisplaced intra-operative acetabular
fracture. Complications for the Two-Incision Mini were 5 intra-
Acetabular Revision using Trabecular Metal with operative fractures, 7 nerve injuries, 1 wound infection, 1 infec-
Limited Host Bone Contact tion requiring revision and 1 PE The G3 minimally invasive
Catherine Kellett, FRCS (Tr & orth)/Dr, Toronto, Canada approach for THA has advantages over the 2 incision mini:
(n) Shorter operative time, no fluoroscopy, fewer days in hospital,
Robert Story, MD, Toronto, ON Canada (n) shorter total incision length and lower complication rate
Robert Korley, MD, Calgary, AB Canada (n) POSTER NO. P027
David Backstein, MD, Toronto, ON Canada (e – Zimmer)
Allan E Gross, MD, Toronto, ON Canada (e – Zimmer)
THA in Patients with Pelvic Radiation Osteonecrosis:
Abstract: Trabecular Metal acetabular components are known to Treatment with a Flanged Acetabular Component
have high porosity, excellent initial stability, and modulus of Michael J Christie, MD, Nashville, TN (a, c)
elasticity similar to trabecular bone. This study describes the David Kent DeBoer, MD, Nashville, TN (a)
early clinical and radiographic results of acetabular revision J Craig Morrison, MD, Nashville, TN (a)
using Trabecular Metal (TM) cups with 58 percent of the cases Martha Brinson, RNCS, Nashville, TN (n)
achieving 0 to 50 percent contact with bleeding host bone
Abstract: Radiation osteonecrosis of the pelvis is a condition for
Patients were informed and consented prospectively. A trans-
which there are very few treatment options. The bone of the
trochanteric approach was use. TM cups were used with
acetabulum in these patients has little or no potential for
cemented polyethylene liners. The percentage contact with
ingrowth, making stable fixation of implant to host exceedingly
bleeding host bone was recorded, and percentage contact with
difficult to achieve. We report the results of eight total hip arthro-
morcellised bone graft or structural graft. Follow up included
plasties (THA) in 6 patients with an underlying diagnosis of
Harris and Oxford Hip Scores and standardised radiographs.
pelvic radiation osteonecrosis after insertion of a flanged acetab-
Radiographic appearance was categorised as loose, new lucency,
ular component. Six female patients with a diagnosis of pelvic
stable, or filling in 48 patients at a mean of 30 months follow
radiation osteonecrosis were treated with total hip arthroplasty,

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
391
PPSE 07:Layout 1 1/12/07 1:40 PM Page 392

four primary THAs and four revision THAs. Two patients died POSTER NO. P029
less than 2 years postoperatively from causes not related to their Mid-Term Results of the Uncemented Mayo Stem in
arthroplasty, leaving six hips followed for a mean of 7 years. The
operative technique in all cases included insertion of a custom- Young Patients
designed and manufactured Triflange component and a cement- Javier Jimenez-Cristobal, MD, Madrid, Spain (*)
less femoral component. No component has been removed. Pedro Jose Torrijos Garrido, MD (*)
One component has progressively migrated. This patient is a Pablo De La Cuadra Virgili, Madrid, Spain (*)
minimal ambulator secondary to advanced metastatic cancer, Jose Luis Vilanova, MD, Madrid, Spain (*)
but reports no complaints with her hip. Other complications
Abstract: This implant was developed at the Mayo Clinic,
include one patient with bilateral arthroplasties who dislocated
between 1982 and 1985, and was incorporated in a short,
each side. Harris Hip Scores improved to a most recent mean of
double-tapered proximal femoral replacement with a modular
85. The Triflange Cup maintains implant stability by achieving
head and neck. The purpose of this study is to evaluate the mid-
intimate contact between implant and host bone beyond the
term outcome in patients who have severe degenerative arthritis
necrotic acetabulum on the more viable host bone of the ilium
of the hip.Between 2000 and 2002, forty-four patients who have
and ischium. This is the only series to report successful results
severe ostheoarthritis were treated with this implant. The average
with a single treatment modality for this diagnosis. Approaching
age at index arthroplasty was 49.3 (31 to 59), and the duration
long term, this technique provides an excellent solution to a very
of follow-up averaged 4.5 years (3 to 6). X-ray and clinical data
difficult reconstructive challenge.
were collected prospectively. Clinical evaluation was carried out
with the Merle d’Aubigne score. The underlying diagnosis for the
POSTER NO. P028
procedures was degenerative arthritis in 20.7 percent, avascular
Is There a Role for Intraoperative Blood Salvage? necrosis in 50.6 percent, pos-traumatic arthrosis in 15 percent,
Camilo Restrepo, MD, Philadelphia, PA (n) failed previous surgery in 3.4 percent and cogenital dislocation
Rachel Trappler, Philadelphia, PA (n) of the hip in 10.3 percent. Hardinge approach was employed in
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) 42 patients and posterior approach in 2 cases.Merle d’Aubigne
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker) score was 9.28 preoperatively and improved to 16.24 at the latest
follow-up. 29.5 percent of patients (13) required blood transfu-
William J Hozack, MD, Philadelphia, PA (e – Stryker)
sion. The complications occurring in 8 patients: 7 proximal
Abstract: Intraoperative blood salvage (IOBS), with less risk than femoral fractures (proximal to the lesser trochanter and undis-
allogenic transfusion, is often used during orthopedic proce- placed) and 1 sciatic palsy. There were no-reoperations for any
dures when a large amount of blood loss is expected. This reason. Mayo implant provided relief of the pain and stiffness
prospective study was designed to examine the effectiveness of and improved range of motion. This implant violate as little
IOBS in reducing the need for allogenic transfusion. Other issues bone as possible and has the theoretic advantage of being easily
such as the safety, cost, and quality of salvaged blood were also revised. This would suggest that is a safe option for patients who
evaluated. The study also intended to identify the group of are younger and more active.
patients who benefited most from blood salvage. 251 (147
female, 104 male) consecutive patients receiving IOBS were
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

POSTER NO. P030

included. The mean age and BMI of patients was 64.2 years and
28.5 Kg/m, respectively. All patients underwent complex hip The Use of an Alumina-On-Alumina Bearing
revison arthroplasty. Blood salvage was performed using the System in THA for Avascular Necrosis of the Hip
Cobe Cardiovascular Brat 2 Autologous Blood Recovery System. Thorsten M Seyler, MD, Baltimore, MD (n)
A mean of 543.6 cc (range, 50 to 4300 cc) of blood per patient Peter M Bonutti, MD, Effingham, IL
was salvaged in this cohort. Salvaged blood was sufficient for (e – Stryker Orthopaedics, d, e – Bonutti Technologies)
retransfusion in 131 patients (52%). Autologus predonated
Mark A Kester, PhD (e – Stryker Orthopaedics)
blood was retransfused in 103 patients on the day of surgery. 208
patients required additional allogenic transfusions. The average Michael A Mont, MD, Baltimore, MD
pre-op hemoglobin was 13.04. Mean hemoglobin was 10.05 at (e – Stryker Orthopaedics, Wright Medical Technology,
post-op day 1 and 9.81 at post-op day 3. The average cost was a – TissueLink, Ossacur)
$650 per unit blood salvaged. IOBS has a low yield when used Abstract: The results of total hip arthroplasties in patients with
non-selectively and is associated with a relatively high cost. It avascular necrosis of the femoral head have not always been
appears that IOBS may not sufficiently reduce the need for allo- optimal. Alumina-on-alumina interfaces appear to be an attrac-
genic transfusion. Patients with low hemoglobin (<13 g/dL), tive alternative for young and active patients with this disease to
high BMI (35 Kg/ m), or those undergoing hip procedure that attempt to lower wear rates to avoid aseptic loosening. The
may result in at least 850 cc of blood loss are better candidates purpose of this study was to evaluate the safety and efficacy of an
for IOBS. alumina-on-alumina bearing in avascular necrosis patients and
compare these results to a group of osteoarthritis patients. In
addition, the authors compared these results to hip arthroplas-
ties with conventional cobalt-chrome-on-polyethylene bearings.
Patient were selected from a United States investigational device
exemption, multi-center, prospective, randomized clinical study
that was initiated in 1996. Seventy patients (seventy-nine hips)
with avascular necrosis were randomized to three cementless
alumina-on-alumina bearing systems and directly matched to
osteoarthritis patients who received the same bearing system.
The results of alumina-on-alumina bearings were also compared
to cementless cobalt-chrome-on-polyethylene bearings in fifty

392 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 393

patients (fifty-two hips). All patients received a cementless were there any progressive radiolucencies. The short-term results
hydroxyapatite-coated femoral stem, and were followed both for metal-on-metal total hip resurfacing for this difficult patient
clinically and radiographically. The clinical outcomes for population were excellent and comparable to patients with
alumina-on-alumina bearings in avascular necrosis and osteoarthritis. The authors await long-term results to see if these
osteoarthritis patients were similar. The seven-year survival prob- early results are maintained for this difficult to treat, young
ability for the alumina-on-alumina bearing was 95.5% for the patient population.
avascular necrosis patients and 89.4% for the osteoarthritis
patients. The mean preoperative HHS in the avascular necrosis POSTER NO. P032
and the osteoarthritis alumina-on-alumina groups were 46 Long-Term Results of 586 Cementless Primary
points (range, 19-74 points) and 50 points (range, 23-82 points)
and improved to 96 points (range, 49-100 points) and 96 points
Total Hip Arthroplasties Using HAC Coated
(range, 71-100 points), respectively. For the cobalt-chrome-on- Endoprosthesis
polyethylene bearing group, the survival probability for avas- Raghu Raman, MRCS, Normanton, West Yorkshire,
cular necrosis and osteoarthritis was 92.3% and 92.9%, United Kingdom (n)
respectively. Preoperative HHS for the avascular necrosis and the Vasanth Eswaramoorthy, MD (n)
osteoarthritis group were 42 points (range, 21-78 points) and 49
David Dickson, MD (n)
points (range, 22-69 points) and increased to 96 points (range,
71-100 points) and 97 points (range, 83-100 points), respec-
Tiru Madhu, MRCS (n)
tively. There was no statistical difference among the survival Peter Angus, FRCS, Dewsbury, United Kingdom (n)
probabilities among the four groups. The results for alumina-on- Abstract: We aim to report the clinical and radiological outcome
alumina and cobalt-chrome-on-polyethylene bearings in of consecutive primary hip arthroplasties using the JRI-Furlong
cementless standard total hip arthroplasties in avascular necrosis Hydroxyapatite ceramic (HAC) coated femoral and acetabular
and osteoarthritis patients were comparable. The low revision components We reviewed 586 consecutive cementless primary
rate is encouraging and offers a promising option for younger, THA using HAC coated components in 542 patients, with a
more active patients with this difficult problem. minimum 12-year follow-up to 18 years, performed at one insti-
tution between 1986 and 1994. Twenty eight (32 THA) were lost
POSTER NO. P031 prior to 12-year follow-up, leaving 514 patients (554 THA) avail-
Metal-on-Metal Hip Resurfacing in Avascular able for study. Threaded cups were used in 64% and press-fit
cups with screws in the rest. Fully HAC coated stems were used
Necrosis of the Femoral Head in all patients. The clinical outcome was measured using Harris,
Michael A Mont, MD, Baltimore, MD Charnley and Oxford hip scores. Anterior thigh pain was quan-
(a, e – Wright Medical Technology) tified on a visual analogue scale (VAS) and quality of life using
Thorsten M Seyler, MD, Baltimore, MD (n) EuroQol EQ-5D. Radiographs were systematically analysed for
David R Marker, BS, Baltimore, MD (n) implant position, loosening, migration, osteolysis and stress
shielding. Polythene wear was digitally measured. The radi-
German A Marulanda, MD, Baltimore, MD (n)
ographic stability of the femoral component was determined by

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

Ronald Emilio Delanois, MD, Lutherville, MD (*)
Enghs criteria The mean age was 75.2 yrs. Dislocation occurred
Abstract: With the advent of improved metal-on-metal designs, in 12 patients (3 recurrent). Re operations were performed in 11
total hip resurfacing has emerged as a viable arthroplasty option. patients (1.9%). Four acetabular and one stem revisions were
However, it remains controversial whether this procedure should performed for aseptic loosening. Other re-operations were for
be used in patients with avascular necrosis where the femoral infection (2), periprosthetic fractures (2), cup malposition (1),
resurfacing component is cemented on to dead bone. The revision of worn liner (2). The mean Harris and Oxford scores
purpose of this study was to analyze the clinical and radi- were 89 (79- 96) and 18.4 (12-32) respectively. The Charnley
ographic outcomes of metal-on-metal total hip resurfacing score was 5.7 (5-6) for pain, 5.3 (4-6) for movement and 5.4 (4-
arthroplasty in patients with avascular necrosis of the femoral 6) for mobility. Migration of acetabular component was seen in
head and to compare these to a matched group of patients diag- 4 hips. Acetabular radiolucencies were present in 54 hips
nosed with osteoarthritis. Forty-two hips with avascular necrosis (9.7%). The mean linear polythene wear was 0.06mm/year.
treated with a metal-on-metal total hip resurfacing arthroplasty Stable stem by bony ingrowth was identified in all hips
were studied. They were matched for gender, age, surgeon, and excluding one femoral revision case. Mean stem subsidence was
surgical approach to another group of osteoarthritic hips treated 2.2mm (0.30- 3.4mm). Radiolucencies were present around 37
with the same metal-on-metal prosthesis. In the avascular (6.6%) stems. Mean EQ- 5D description scores and health ther-
necrosis group, there were 25 men and 11 women and in the mometer scores were 0.81 (0.71-0.89) and 86 (64-95). With an
osteoarthritis group there were 28 men and 13 women. The end point of definite or probable loosening, the probability of
mean age at the time of surgery was 42 years (range,18-64 years). survival at 12 years was 96.1% for acetabular and 98.3% for
Patients were followed both clinically and radiographically for a femoral components. Overall survival at 12 years with removal
mean of 41 months (range, 24-61 months). The clinical or repeat revision of either component for any reason as the end
outcomes were similar for both groups with good and excellent point was 97.2%. The results of this study support the continued
results (HHS equal or greater than 80 points) in 39 hips (93 use of a fully coated prosthesis and documents the durability of
percent) and 40 (98 percent) for avascular necrosis and the HAC coated components. In our clinical experience, the
osteoarthritis, respectively. The mean HHS score in the avascular Furlong prosthesis revealed encouraging radiographic stability
necrosis group was 91 points (57-100 points) and in the over a long term period.
osteoarthritis group 91 points (49-100) (p=0.867). Survivorship
curves were similar for the two patient groups (p=0.977). In
both groups there were two failures that required conversion to
a standard total hip arthroplasty. Radiographic analysis did not
reveal any change in position of the implanted prostheses, nor

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
393
PPSE 07:Layout 1 1/12/07 1:40 PM Page 394

POSTER NO. P033 prostheses technology has led to the reemergence of resurfacing
Randomized Prospective Comparison between as a viable option for total hip arthroplasty. There are a limited
number of studies evaluating the results of current metal-on-
Duration® and Conventional UHMWPE: Seven Year metal designs. As part of a comprehensive FDA IDE evaluation,
Results this study provides the clinical and radiographic outcomes of a
Kazuo Hirakawa, MD, Kamakura, Japan (e – Zimmer) metal-on-metal resurfacing at mid-term follow-up. Between
Ichiro Tatsumi, MD, Osaka, Japan (n) August 2000 and August 2003, 1016 metal-on-metal hip resur-
facings were performed by ten orthopaedic surgeons in an FDA-
Satoshi Nakasone, Okinawa, Japan (n)
IDE study. The most common indications for surgery were
Masaki Shiono, MD, PhD (n) primary osteoarthritis (77%), osteonecrosis (11%), hip dysplasia
Abstract: This study evaluates the effect of Duration® UHMWPE (7%), and trauma (4%). The mean patient age was 50 years
(PE) compared to conventional PE gamma irradiated in air for (range, 15-81 years) with a mean follow-up of 51 months (range,
primary THA averaged 7 years follow-up. Forty-eight primary 33 to 69 months). The mean body mass index was 27.5 (range,
THA were performed for all women DDH patients with 16.3 to 48.2). All patients were evaluated using Harris Hip Scores
randomization. Group I had 28 Duration® PE (Stryker), and and SF-12 Health surveys. Patients were radiographically
Group II had 20 same design PE gamma irradiated in air. Same assigned for alignment, loosening and lucencies. After an inves-
design acetabular shell, uncemented-stems, and 22 mm femoral tigator meeting in October 2002, the prosthesis was slightly
head was used in both groups. Averaged age in Group I and II altered (thin acetabular shells), the indications modified
was 64 and 63, follow-up was 89 and 87 months, respectively. (excluded BMI >35, osteopenia), and the technique changed
Wear measurement was performed with Martell’s method. (cementing, no notching allowed). At final follow-up, 867 hips
Averaged 2-D wear rate was 0.069 mm/year in Group I and 0.119 (85%) were considered to have successful clinical outcome
in Group II (p<0.05). Three dimensional rate in Group I and II based on a Harris Hip Scores greater than or equal to 80 points.
showed 0.124 and 0.192 mm. Seven bilateral patients with The mean Harris Hip score improved from 47 points (range, 3
different PE showed Duration® had lower penetration in both to 92 points) preoperatively to 87 points (range, 3 to 96 points)
2D (0.06 mm in Group I, 0.113 in Group II) (P<0.05) and 3D postoperatively, p<0.001. The mean final follow-up SF-12
(0.114 mm and 0.149) (p<0.05). First and second year had mental and physical component scores were 55 points (range,
higher rate in both groups compared to after 3rd year. Thicker 19-67 points) and 50 points (range, 17 to 64 points), respec-
polyethylene had lower penetration in both groups (p<0.05). tively. There were 45 hips (4%) that required revision surgery
One acetabular cup with conventional PE has revised by loos- with the most common indications being fractures (19 hips)
eningwith osteolysis. Sycterz reported penetration was higher in and component loosening (12 hips). One patient experienced
first several years. Wroblewski demonstrated 22mm head had protrusio acetabuli which required surgical revision.
0.21 mm/year penetration averaged 86 months. This study Postoperative dislocations occurred in 18 hips (1.8%).
showed first and second year had higher (probably penetration), Radiolucencies were documented in 157 hips (15%), although
but it stabilized after third year. McKellop reported Duration® PE none were progressive. After changes were made in the prosthetic
had better wear performance compared to other conventional design, indications, and technique, the overall complication rate
PE. Longer follow-up need to clarify the oxidative changes of this was reduced. The revision rate was 4.7% before and 2.8% after
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

type PE in vivo. the changes. This can be exemplified specifically in the femoral
neck fracture rate which was reduced from 2.8% to 0.7%. The
POSTER NO. P034 results of this prospective study illustrate the mid-term durability
Modern Generation Metal-on-Metal Total Hip and effectiveness of metal-on-metal resurfacing across patient
Resurfacings: Results of a prospective FDA-IDE populations and multiple surgeons. In addition, the results indi-
cate that patients should be carefully selected in order to reduce
Study the incidence of femoral neck fracture. After modifications for
Michael A Mont, MD, Baltimore, MD indications, prosthesis, and technique, the femoral neck fracture
(a, e – Wright Medical Technology) rate was reduced from 2.8% to 0.7% which further reflects the
Harlan C Amstutz, MD, Los Angeles, CA significant learning curve for this procedure. The authors await
(e – Wright Medical Technology) long-term follow-up to see if these promising results will be
Harold S Boyd, MD, Salem, OR (e – Wright Medical maintained.
Technology)
POSTER NO. P035
Thomas P Schmalzried, MD, Los Angeles, CA
(e – Wright Medical Technology) Increased Acetabular Polyethylene Wear in Relation
Thomas Parker Vail, MD, Durham, NC to Acetabular Inclination and Femoral Offset
(e – Wright Medical Technology) Robert Barry Bourne, MD, London, Canada (n)
Edward A Sparling, MD, Vancouver, WA John J Gallagher, MD, FRCS (n)
(e – Wright Medical Technology) Constant A Busch, BSc, Chertsey, Surrey, United Kingdom (n)
William R Kennedy, MD, Sarasota, FL Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom (n)
(e – Wright Medical Technology) Reid B Brown, MD, Louisville, KY (n)
Thorsten M Seyler, MD, Baltimore, MD (n) Xunhua Yuan, Lund, Sweden (n)
Victor Goldberg, MD, Cleveland, OH John Martell, MD, FRCSC (n)
(e – Wright Medical Technology) Cecil H Rorabeck, MD, London, Canada (n)
Abstract: Due to concerns of component loosening and biolog- Abstract: The purpose of this study was to assess the influence of
ical incompatibility of the alloy constituents, the first generation acetabular inclination and the restoration of femoral offset of
of metal-on-metal bearings were phased out shortly after being polyethylene wear. Forty-two patients who underwent a total hip
introduced in the 1960’s. Recently, improved metal-on-metal arthroplasty using an uncemented Mallory-Head tapered

394 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 395

femoral stem and Ring Loc acetabular shell were assessed at a POSTER NO. P037
minimum of 60 (mean of 89.5 ± 9.6) months for acetabular Comparison of the Skin Blood Flow Between Mini
polyethylene wear by an independent observer (JMM) unaware
that acetabular inclination and offset were the parameters being and Conventional Incision Approaches During THA
assessed. All x-rays were measured for restoration of femoral Takahiko Kiyama, MD, Fukuoka, Japan (n)
offset and acetabular inclination using Matlab (Math Works, Masatoshi Naito, MD, Fukuoka, Japan (n)
Inc., Natick, MA). Wear was analyzed against acetabular inclina- Yuichiro Akiyoshi, MD, Fukuoka, Japan (n)
tion and restoration of femoral offset using SPSS12.0 (Chicago, Hiroshi Shitama, MD, Fukuoka, Japan (n)
Il.). Mean linear wear for all patients was 0.12 ± 0.1 millimeters Takafumi Kumano, MD, Fukuoka, Japan (n)
per year and mean volumetric wear was 56.1 ± 5.5 millimeters
Tsuyoshi Shinoda, MD, Fukuoka, Japan (n)
per year. Patients with acetabular inclination over 45 degrees had
mean linear wear rates of 0.16 ± 0.03 millimeters per year Akira Maeyama, MD, Fukuoka, Japan (n)
compared to 0.09 ± 0.01 millimeters per year if the inclination Akinori Takeyama, MD, Fukuoka City, Japan (n)
angle was less than 45 degrees (p<0.001). Patients with offset Xie Jun, MD, Fukuoka City, Japan (n)
restored to within 5 millimeters had mean linear wear rates of Abstract: In order to clarify the effects of the length of incision
0.09 ± 0.02 millimeters per year compared to all others with on the local circulation, we measured the skin blood flow in vivo
0.13 ± 0.03 millimeters per year (p<0.06). Acetabular inclination during total hip arthroplasty. The patients were randomly allo-
>45º proved to be an important factor with regards polyethylene cated to have a surgery through either a mini incision of 7 cm
wear with significantly increased (p<0.001). A strong trend (p = (group-M) or a conventional incision of 14 cm (group-C).
0.06) was noted for less wear in cups with restored femoral Twenty patients who underwent total hip arthroplasty were
offset. investigated. 10 patients were operated through the mini inci-
sion whereas the remaining 10 patients were operated through
POSTER NO. P036 the conventional incision THA. A laser Doppler flowmetry was
Cup Inclination Angle and Whole Blood Levels of utilized to measure the intraoperative blood flow of the skin.
The measurements were performed at two regions, namely ante-
Cobalt and Chromium Ions After hip resurfacing rior and posterior regions across the incision. As a control, the
Alister Hart, FRCS, London, United Kingdom (*) skin blood flow over the anterior superior iliac spine was meas-
Pranai Buddhev, BSc (*) ured. The measurements were performed before making a skin
Payam Tarassoli, BSc (*) incision and after implantation, respectively. In the group M, the
Jonathan Powell, PhD (*) average value of skin blood flow at anterior region was decreased
John Skinner, FRCS, London, United Kingdom (*) from 2.4 ml/min/100g to 1.6 (p<0.05), and that at posterior
Abstract: In vitro, the factors that determine wear particle volume region was decreased from 2.2 to 1.5 (p<0.05). While, those
from metal-on-metal (MOM) hip resurfacing include: head size, values in the group C changed from 3.2 to 2.9 at anterior (N.S.)
clearance, surface roughness and carbide density. However, in and from 3.3 to 3.2 at posterior regions (N.S.). The values of
vivo there are additional factors including: bilateral implants control were constant in both groups during operation. The skin
blood flow in mini incision THA was significantly decreased

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

and time from operation. Studies of metal on polyethylene bear-
ings show an association between wear and acetabular inclina- during operation. The reduction of this skin circulation may be
tion, but there is no published correlation for metal on metal caused due to the excessive forces applied to the tissue by retrac-
bearings. Using standardised radiographs, we measured the tors to expose the hip joint.
inclination angle (using UTHSCSA image tool) of the acetabular
POSTER NO. P038
components in thirty-one patients (mean age 54 years) who
underwent unilateral Birmingham hip resurfacing (mean time The Jubilee Method: A Novel, Effective Wound
post operation of 22 months). We measured whole blood Dressing Following THR and TKR
chromium and cobalt ions using inductively coupled mass spec- John Dillon, MRCS, Glasgow, United Kingdom (n)
trometry (detection limit 10 parts per trillion). All components
Jon Clarke, MBChB (n)
were well fixed. There was a positive correlation between the
acetabular inclination angle (range 28º - 55º) and whole blood Andrew Kinninmonth, FRCS (n)
concentration of Cobalt (range 2.3 - 7 mcg/L), Chromium Abstract: Modern dressings - such as Molndal (2002) - have been
(range 0.56 - 4.3 mcg/L) and total metal ion levels (range 3.1 - shown to be more effective than standard dressings. They reduce
10.3 mcg/L). This finding was statistically significant, with a patient morbidity due to wound healing problems such as blis-
Pearson correlation coefficient of 0.46 (95% CI 0.13-0.70) and tering, frequent and early dressing changes, and potentially
a p-value of 0.00398. Acetabular inclination angle is likely to be avoid prolonged hospitalization. The Jubilee Method is a novel
a factor in determining the metal ion level following hip resur- wound dressing based upon Molndal, consisting of Aquacel and
facing. We identified a threshold level of 50º inclination, after Duoderm extrathin. Its efficacy has been evaluated in this study
which metal ion levels rise dramatically. We recommend by comparison to a standard dressing (Aquacel and Mepore). A
surgeons implant the metal socket at an inclination angle of less prospective, randomized controlled trial was conducted
than 50º. involving 400 patients undergoing primary elective total hip
(THR) or total knee (TKR) arthroplasty. Patients were random-
ized to receive one of the two dressings. Incidence of blistering,
surgical-site infection (SSI) rate, number of dressing changes, day
of first dressing change, and delayed discharge due to wound
problems were noted. 380 forms were successfully completed.
The incidence of blistering was 1.9% in the Jubilee group, and
19.1% in the Standard group. First day dressing change was 3.77
in the Jubilee group, compared with 2.26 in Standard group.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
395
PPSE 07:Layout 1 1/12/07 1:40 PM Page 396

Total mean number of dressings was 1.57 for Jubilee, and 3.2 POSTER NO. P040
Standard. Delayed discharge due to wound problems was 1.9% Five to twelve year follow-up of hip resurfacing in
Jubilee, and 8.7% Standard. SSI rates were 0.4% Jubilee, and
1.9% Standard. The Jubilee method group demonstrated a later patients under the age of 55 with osteoarthritis
first day dressing change, fewer dressing changes, less blistering, Joseph Daniel, FRCS, Birmingham, United Kingdom
fewer delayed discharges, and a lower SSI rate compared to the Chandra Pradhan, FRCS, Birmingham, United Kingdom
standard dressing. The Jubilee method is a highly effective Hena Ziaee, BSc, Birmingham, United Kingdom
dressing in primary total knee and total hip arthroplasty proce- Pynsent Paul, PhD, Birmingham, United Kingdom
dures. Derek J.W. McMinn, FRCS, Birmingham, United Kingdom
POSTER NO. P039 Abstract: The results of conventional hip replacements are worse
in young patients than in other groups. Hip resurfacing is a bone
Do Hooded Acetabular Liners Increase the conserving option and has been showing encouraging early
Incidence of Prosthetic Impingement After THR? results from several centres. Continued monitoring of early
Molly M Usrey, BS, Houston, TX (a – Plus Orthopedics) cohorts of resurfacings will reveal their medium and long-term
Lanny Joseph Rudner, MD, Houston, TX survival. This is a retrospective study of two cohorts of patients
under the age of 55 with osteoarthritis treated with hybrid-fixed
(a – Plus Orthopedics)
metal-metal resurfacings. The cohorts are a) 43 consecutive hips
Philip C Noble, PhD, Houston, TX (a, b, c, e – Plus treated by the senior author in 1994 and 95 with a hydroxyapatite-
Orthopedics, Zimmer, a, c – Stryker, a, b – Medtronic) coated smooth uncemented cup and a cemented femoral compo-
Michael A Conditt, PhD, Houston, TX nent and b) 403 consecutive patients treated with
(a – Plus Orthopedics) hydroxyapatite-coated porous uncemented cup and a cemented
Michael V Birman, MD, Ann Arbor, MI femoral component between 1997 and 2001. Mean age at opera-
(a – Plus Orthopedics) tion was 48.3 years. Ten patients (11 hips) died from unrelated
Richard F Santore, MD, San Diego, CA causes. Out of the remaining 435 hips (374 patients) at a follow-
(a – Plus Orthopedics) up of 5 to 12 years (mean 7.1 years), there was one failure (cumu-
lative failure rate 0.2% at 12 years) from avascular necrosis of the
Kenneth B Mathis, MD, Houston, TX
femoral head. The mean Oxford score of the 374 patients (434
(a, e – Plus Orthopedics) hips) is 13.4. 87% had a UCLA score of 7 and above. 55% partic-
Abstract: Impingement of the femoral neck on the acetabular ipated in impact sports or were involved in heavy occupational
liner is a function of joint range of motion, implant head:neck work. In the present study, excellent survival (99.8%) was seen in
ratio, and acetabular liner design and position. Hooded acetab- spite of high activity level. The extremely low failure rate in the
ular liners are frequently used to increase joint stability, but can medium term proves the suitability of resurfacing in young active
potentially increase the probability of impingement if the liner patients. However, caution needs to be exercised until long term
is malpositioned. As such, there is uncertainty over the utility of results are available.
hooded acetabular liners. 113 acetabular components were
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

retrieved during revision total hip arthroplasty after an average POSTER NO. P041
time in situ of 76 months. Each acetabular liner was examined
with incident light and inspected for presence, location, and ◆The Results Of Uncemented Total Hip Arthroplasty
severity of signs of impingement. The presence of a liner hood In Patients with Juvenile Idiopathic Arthritis
along with angle, height, and type of hood were recorded. The Johan Witt, MD, Maida Vale London, United Kingdom (*)
depth of penetration of the femoral head into the acetabular Vijayaraj Kannan, MD, London, United Kingdom (*)
liner was also measured. Approximately one-third (34%;38/113) Abstract: We report the results of a prospective study of unce-
of the liners examined had impingement damage graded as mented THA in young patients with JIA with a minimum
moderate or severe. Impingement was only slightly more preva- follow-up of two years 54 patients with 78 arthroplasties were
lent in hooded liners compared to neutral liners (35% vs. 29%). available for review. The mean age at operation was 18 years (10
In the hooded liners examined, the site of impingement was to 29). The average follow up was 6 years (2 to 10). Three
located on the elevated portion of the rim in 85% (44/52) of different types of stem were used depending on size and
components, and was restricted to the neutral portion in only 8 anatomy. Three different uncemented cups were used and in 4
of the liners examined (15%; 8/52). Hooded liners with cases a support ring and cemented cup was used. The hips were
impingement damage displayed three times the depth of head graded before surgery and at follow-up using the Hospital for
penetration in the liner than those without impingement Special Surgery scoring system. The mean improvement in the
(1.56mm vs 0.52mm). This study demonstrates that hooded pain score was 6.3 and the total score improved from and
liners rarely function as intended. Though it has been assumed average of 15 to 32. Overall a revision procedure was required in
that hooded liners increase head containment without 7 hips. Liner revision was performed in 4 hips. Two cups were
neck/liner impingement, in practice, a far more common revised for loosening (1 SROM and 1 reinforcement ring) and 1
scenario is impingement of the neck on the elevated section of stem (SROM) which had never osseointegrated. In the
the liner leading to significant surface damage and reduced remaining hips radiographic analysis revealed well osseointe-
range-of-motion. This suggests that improved designs and grated stems in 74 hips. There was stable subsidence of 1
surgical guidelines are needed to enable correct placement of the CADCAM stem not requiring revision, and subsidence of 2
elevated segment of hooded liners to minimize unexpected CADCAM stems due for revision (8yrs post-op). Radiolucent
impingement, and maximize head coverage during episodes of lines were seen around 3 cups (SROM) and 1 support ring. The
instability. remaining 72 cups demonstrated good osseointegration. This
study shows a lower revision rate and better radiographic
appearance compared to previous reports with similar follow up
of THA in Juvenile Idiopathic Arthritis.

396 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 397

POSTER NO. P042 POSTER NO. P044

Increased Early Revision Rates Associated with Hip 10- to 13-Year Follow-up of a Fiber-metal Porous
Surface Replacement Coated Acetabular Component in Primary THA
Alexandra M Claus, MD, Mannheim, Germany (n) Allen P McDonald, III MD, Atlanta, GA (n)
Markus Schwarz, MD, Mannheim, Germany (n) Alexander P Sah, MD, Boston, MA (n)
Hanns-Peter Scharf, MD, Manheim, Germany (n) Henrik Malchau, MD, Boston, MA
Abstract: Hip surface replacement provides one possible bone- (a – Zimmer, Biomet, a, e – Smith and Nephew)
preserving option in adult hip reconstruction. When introducing Charles R Bragdon, PhD, Boston, MA (a, d – Zimmer)
this new technique, we have initiated a concomitant observa- Harry E Rubash, MD, Boston, MA (e – Zimmer)
tional study to monitor complications and revisions. From July William H Harris, MD, Boston, MA (a, c – Zimmer)
2004 to May 2006, 52 ASR (Articular Surface Replacement,
Abstract: The Trilogy acetabular component has a hemispherical
Depuy, a Johnson&Johnson Company, Warsaw, U.S.A) have
geometry and the same titanium fiber-metal porous in-growth
been implanted by a single experienced adult hip reconstruction
surface as the Harris-Galante designs, but has an improved
surgeon. Patients requiring revision for any reason were consid-
locking mechanism, optimized screw-hole configurations, and
ered as failures. Indications for surface replacement were
less backside wear. The purpose of the current study is to eval-
recorded and failure mechanisms were assessed using microra-
uate the mid to long-term survivorship of the Trilogy acetabular
diographs of sectioned femoral necks. 45 ASR have been
component. One hundred and eight consecutive patients under-
performed for primary osteoarthritis (OA), 4 cases for secondary
went 115 primary total hip arthroplasties by a single surgeon
osteoarthritis (2 slipped capital epiphyses, 1 rheumatoid
using the Trilogy acetabular component with conventional poly-
arthritis, 1 status following septic hip arthritis) and 3 cases for
ethylene and cemented stems. At the time of final review, 27
avascular necrosis (AVN). To date, 6 revisions (11.5%) have been
patients had died and 6 patients were lost to follow-up. Seventy-
performed, one cup loosening was caused by low-grade infec-
five patients (79 hips) with 10 to 13-year follow-up were avail-
tion (primary OA), two cases for progressive necrosis of the
able for clinical and radiographic review. The Harris Hip Score,
femoral neck resulting in femoral neck fractures (one rheuma-
UCLA, WOMAC, and EQ5D scores were captured at follow-up.
toid arthritis, one AVN), two for unclear pain caused by progres-
Radiographs were reviewed for evidence of osteolysis, loosening,
sive osteolysis and subsequent microfracturing of the femoral
and subsequent migration. In the 75 living patients with
neck (both primary osteoarthritis) and one for malpositioning
minimum 10-year follow-up, 77 of 79 cups (97.5 percent)
with load-depending pain during all activities (primary
remained unrevised. Two cups were revised for mal-position
osteoarthritis). There is increased early revision rate associated
with recurrent instability. Both cups were well fixed at the time
with hip surface replacement. Careful patient selection and
of revision. Of the 27 patients (30 hips) that died and 6 patients
implant positioning seem to be crucial. To reduce revision rates
(6 hips) lost to follow-up, two patients underwent cup revision
in hip surface replacement, we have restricted indications to
for recurrent instability. At final follow-up, five cups were associ-
primary osteoarthritis and introduced navigation to improve
ated with minor osteolysis but without radiographic evidence of
implant positioning of the femoral component
loosening or migration. The current study suggests excellent 10

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

to 13 year survivorship of the Trilogy acetabular component. No
POSTER NO. P043
cup was revised for reasons related to aseptic loosening, osteol-
Early Failure in a Series of Hybrid Total Hip ysis, infection, or mechanical failure of the locking mechanism.
Arthroplasties
Alberto E Martinez, MD, Bogota, Colombia (n) POSTER NO. P045
Augusto Sarmiento, MD, Miami, FL (n) Modular Cementless Total Hip Arthroplasty in
Abstract: Hybrid total hip arthroplasty has reached similar results Patients with Multiple Epiphyseal Dysplasia
to those with classic cemented prostheses. Early failure of hybrid Youn Soo Park, MD, Seoul, Republic of Korea (n)
total hip arthroplasties has been recently reported with the Elite ® Young-Wan Moon, MD, Seoul, Republic of Korea (n)
stem (De Puy). We found similar early aseptic loosening with the
Seung-Jae Lim, MD, Seoul, Republic of Korea (n)
use of this system. We reviewed retrospectively our series of 61
Sang-Soo Eun, MD (n)
consecutive total hip arthroplasties performed on 51 patients with
hybrid technique using Elite ® femoral stems implanted with third Kyoung-Hwan Koh, MD (n)
generation cementing technique. Patients had a mean follow up Abstract: Patients with short stature and osseous deformities
of 6 years and one month. Six patients died of unrelated causes resulting from multiple epiphyseal dysplasia (MED) frequently
months after surgery. Multivariate analysis was performed to have precocious development of advanced degenerative arthritis
define differences between revised or radiologically loose and of the hip and thus may require total hip arthroplasty (THA). The
clinically successful cases Eleven (18 percent) of the 61 arthro- purpose of this study was to present the results of THA using a
plasties have been revised up to date for aseptic loosening of the modular cementless femoral stem in patients with MED and
femoral stem. Another 4 (6.5%) have radiological evidence of advanced osteoarthritis of the hip. We analyzed a consecutive
loosening. Most revisions (63 %) were performed at a date later series of twenty-three that had been performed using modular
than 6 years after the primary surgery. None of the revisions (six) cementless prostheses in thirteen patients with a confirmed diag-
performed by the senior author demonstrated any evidence of nosis of multiple epiphyseal dysplasia and end-stage osteoarthritis
infection. Even though the Elite stem was designed with a similar of the hip. Clinical, radiographic, and biomechanical evaluations
shape to that of the Charnley stem, results have been disap- were performed at a minimum of two years following the index
pointing in our series as well as in other recently reported series. arthroplasty. Mean patient age at the time of index arthroplasty
Caution should be applied in the follow-up of patients implanted was 47.2 years and the mean duration of follow-up was 4.8 years
with this stem, with more frequent radiological controls, as well (range, 2 to 8 years). The mean Harris hip score improved from
as in the use of the Elite stem in primary arthroplasties. 40.6 points preoperatively to 93.8 points at the time of the latest

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
397
PPSE 07:Layout 1 1/12/07 1:40 PM Page 398

follow-up (p < 0.001). Postoperatively, all hips demonstrated external iliac vessels were measured at the level of 1 cm below
favorable alterations in the biomechanical parameters including the acetabular dome to the 3 cm superior to the acetabular
hip center of rotation, femoral offset, femoral neck length, and dome. The shortest distances from the external iliac vessels to the
limb length. At a mean follow-up of 4.8 years, no hip required nearest cortex of the pelvis and direction from the femoral head
revision because of aseptic loosening of the acetabular or femoral to the iliac vessels were measured bilaterally at each level. Similar
component. One patient (one hip, 4.3%) underwent reoperation data were obtained in the coronal plane. At the level of 1 cm
for polyethylene wear and osteolysis eight years after index arthro- below the acetabular dome, the distance from the external iliac
plasty. Our data suggest that the modern modular implant designs vein to the pelvis averaged only 4 millimeters and at the level of
combined with refined surgical techniques offer a promising superior to the acetabular dome, this distance increased. At each
medium-term outcome for these relatively young patients with level, the external iliac vein was closer to the pelvis than the
severe anatomical deformities. external iliac artery. The left side external iliac vessels were closer
to the pelvis than those in the right side. The external iliac vessels
POSTER NO. P046 are at risk of injury when penetration occurs in the anterosupe-
Total Hip Arthroplasty using Short External Rotator rior region of the acetabulum. The external iliac vein appears to
be more vulnerable than the artery because of its more medial
Preserving Posterior Approach position and the paucity of psoas muscle. To avoid vascular
Yong Sik Kim, MD, Seoul, Republic of Korea (e – Corentec) injuries, knowledge of the location of the external iliac vessels is
Soon Yong Kwon, MD, Seoul, Republic of Korea (n) of critical importance.
Suk Ku Han, MD, Seoul, Republic of Korea (n)
Doo Hoon Sun, MD, Seoul, Republic of Korea POSTER NO. P048
(d – Corentec) The Sensitivity of Gram Stains from Multiple Sites
Jung Man Kim, MD, Seoul, Republic of Korea (n) in Patients with Infected Total Hip Arthroplasty
Hyoun-Ee Kim, PhD, Seoul, Republic of Korea (n) David R Marker, BS, Baltimore, MD (n)
William J Maloney MD, Stanford, CA (c – Zimmer) Thorsten M Seyler, MD, Baltimore, MD (n)
Abstract: We modified the posterior approach to the hip by Ronald Emilio Delanois, MD, Lutherville, MD (n)
preserving the external rotator muscles in order to enhance joint
Johannes F Plate, BS, Heidelberg, Germany (n)
stability after total hip arthroplasty. The aim of the this study was
Michael A Mont, MD, Baltimore, MD
to determine the influence of external rotator preserving posterior
approach in primary total hip replacement on early dislocation (e – Stryker Orthopaedics, Wright Medical Technology)
and progression of rehabilitation. Six hundred seventy primary Abstract: Periprosthetic infections remain one of the most chal-
total hip replacements were divided into three groups based on lenging complications in total joint arthroplasty. In order for
how the external rotators were treated at surgery. External rotator orthopaedic surgeons to provide appropriate management of
preservation (Group 1, 220 hips) was compared with reattach- these infections, it is important to have a powerful set of diag-
ment (Group 2, 282 hips) and no repair (Group 3, 168 hips) by nostic methods. There has been controversy concerning the role
evaluating the clinical and radiographic outcome at one year post- of gram staining of a variety of tissue and fluids for suspected
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

operative. Anteversion was significantly less in Group 1 as infections. Nevertheless, gram stains continue to remain a
compared to Group 2 (P < 0.001) or 3 (P < 0.001). There was no commonly used modality for diagnosing infections. This study
significant difference in inclination among the groups (P > 0.05 in compared the efficacy of gram staining from multiple media,
all comparisons). No dislocations were found in 220 hips with (blood, joint aspirations, drainage, and operative-sites) in
external rotator preservation whereas dislocations were noted in patients with known deep infected hip arthroplasties. Between
11 (3.9%) and 9 hips (5.2%) in Groups 2 and 3, respectively. May 21, 1996 and May 23, 2006, gram stains were collected for
Group 1 had the highest mean Harris hip score (97.0±2.9 points) 590 deep infected total hip arthroplasty cases. The gram stains
as compared with either Group 2 (P < 0.001) or 3 (P < 0.001). The were collected from four different sites; blood (20), wound
results of this study showed that external rotators could play an drainage (17), joint aspiration fluid (70), and operative-site
important role in preserving joint stability after total hip arthro- (483) samples. In each case, the gram stains were followed by
plasty. It can be implied that this modified posterior approach cultures. The overall sensitivity of gram stains were analyzed and
would be able to contribute greatly to prevention of dislocation stratified according to the identified cultured organisms. The
and rapid rehabilitation after total hip arthroplasty. effectiveness of the gram stains from each medium was then
analyzed by determining the associated sensitivity, specificity,
POSTER NO. P047 accuracy, predictive value for a positive test, and the predictive
value for a negative test. Overall, the gram stains showed different
Location of the External Iliac Vessels Around the
sensitivity levels depending on the organism. Sensitivity ranged
Acetabulum Using Three-Dimensional CT between 0 to 11% for a number of organisms. It was higher for
Yoshiteru Kawasaki, MD, Tokushima, Japan (n) staphylococcus (20%) and MRSA (41%), but still relatively low.
Koichi Oba, MD (n) With respect to the different sites, the gram stain and culture
Shunji Nakano, Tokushima City, Japan (n) results were identical for samples taken from blood, with 13 true-
Hiroshi Egawa, MD, Alexandria, VA (n) positive and 7 true-negative. Joint aspiration samples showed the
next highest sensitivity at 32%, compared to 25% and 18% for
Natsuo Yasui, Tokorozawa, Japan (n)
drainage and operative-site samples, respectively. All gram stains
Abstract: Vascular injury associated with hip surgery is showed relatively high specificities of 97% or higher, except for
uncommon, but serious complication. The purpose of this study wound drainage, where gram stains reached a specificity of only
was to investigate the location of the external iliac vessels around 78%. The accuracy for each site was 53% for drainage, 54% for
the acetabulum using three-dimensional computed tomography operative-sites, and 59% for fluid. Operative-site samples and
with intravenous contrast. A total of 50 patients (25 males and aspiration gram stains also showed higher predictive values for a
25 females) were randomly chosen and the locations of the positive test (90% and 93%). With the exception of blood

398 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 399

samples, the predictive values for negative test ranged between cases using spiked press fit acetabular components (duraloc 300
50% and 54%. This study found that gram stains were useful for or pinnacle 100 series) over a four year period. In all cases the
blood analyses but had low utility when sampling wound acetabulum was underreamed by 1mm. Spiked press-fit acetab-
drainage, aspirations, and operative-sites. This test should be ular components were used in cases where the senior operating
considered an inefficient modality for identifying deep prosthetic surgeon noted the bone to be of poor quality. We hypothesise
joint infections. Currently, operative-site samples are the most that the use of spikes in poor quality bone may be sufficient to
common location for obtaining gram stains; however, due to act as an additional stress riser, with the oversized component,
their low sensitivity, use should be discouraged because of their to cause a stress fracture of the acetabulum. This highlights the
low utility for diagnosing infections. need for extra care with the use of oversized spiked acetabular
components in such cases.
POSTER NO. P049
Relationship Between Dislocation After Total Hip POSTER NO. P051
Arthroplasty and Preoperative Range of Hip Joint Comparison of Wear Rates Between Highly
Masamori Shigematsu, MD, PhD, Saga, Japan (n) Crosslinked and Traditional Polyethylenes
Takami Higo, MD (n) Amar D Rajadhyaksha, MD, Valhalla, NY (n)
Masaaki Mawatari, PhD (n) Cristian Brotea, MD, Valhalla, NY (n)
Takao Hotokebuchi, MD, Fukuoka, Japan (n) Rama Ramakrishnan (e – Stryker Orthopaedics)
Abstract: Dislocation after total hip arthroplasty (THA) is studied Courtney Kuhn, PA-C (n)
from diverse angles world wide. However, few reports are avail- Yeukkei Cheung, MD, Edgewater, NJ (n)
able on relationship between preoperative range of hip motion Steven B Zelicof, MD, White Plains, NY
and dislocation after THA. The objective of this study was to (e – Stryker Orthopaedics)
clarify this relationship. Between 2000 to 2004, 1288 THAs in Abstract: Highly cross-linked polyethylene can reduce linear wear
882 patients were performed at our hospital. Patients included by 50-90% when compared to traditional polyethylene (gamma
688 women and 194 men. Their average age at the time of sterilized in air) in wear simulator studies. The polyethelene
surgery was 61.7 years . All operations were performed by one under study is irradiated to 10 Mrads to achieve cross linking, and
senior surgeon. We calculated the incidence rates of dislocation cold annealed, but not remelted. The purpose of this study was
and analyzed the preoperative factors that were involved with to compare the linear wear rates of a highly cross-linked polyeth-
this condition. The multiple logistic regression analysis was used ylene to traditional polyethylene. Twenty-seven highly cross-
for statistical analysis. The following variables were recorded into linked polyethylene components (in 25 patients) and 27
the model: incidence of dislocation, age, sex (man=1), original traditional (3 Mrads in inert gas) components (in 25 patients)
diagnosis, history of previous surgery, and preoperative range of were included in the study. The two groups were matched with
hip motion (flexion, exetension, internal rotation, external rota- respect to age, gender, height, weight, and activity level. All
tion, adduction, abduction, fexion-extension arc, internal- surgeries were performed by a single surgeon using the same
external rotation arc). A P value of less than 0.05 was considered implant designs. Linear wear was measured utilizing Martell’s

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

to be statistically significant. Of all the patients who underwent computerized technique. The highly cross-linked group and the
THA, 2.9% (38/1288) had dislocation. Single dislocations traditional group were followed for a mean of 71 months (range,
occurred in 26.3% (10/38) and recurrent dislocation in 73.7% 60 to 87) and 75 months (range, 60 to 97) respectively. The mean
(28/38). Significant risk factors for dislocation were abduction, penetration rate for the highly cross-linked and traditional poly-
internal rotation, external rotation, flexion-extension arc, and ethylene was 0.045mm/yr (SD=0.044) and 0.120 mm/yr
internal-external rotation arc. A close association exits between (SD=0.070) respectively. The mean total penetration for the
preoperative range of hip motion and the incidence of disloca- highly cross-linked group was 0.283 millimeters (SD= 0.253)
tion after THA. We have to examine patients more carefully and and 0.696 millimeters (SD=0.402) for the traditional group. The
to understand their life style, religion, occupation and role of difference in linear wear was highly significant at p=<0.001.
their society. Cross-linking has been shown to improve wear performance of
polyethylene. Our experience demonstrates a 59 percent reduc-
POSTER NO. P050 tion in wear over traditional polyethylene at a minimum of five
Early Failure of Press-Fit Spiked Acetabular years. Highly cross-linked polyethylene significantly reduces wear
Components Due to an Acetabular Fracture and may minimize future osteolysis thus increasing the longevity
of total hip arthroplasty.
Vincent Kent, MBB MRCS, Lisburn, United Kingdom (*)
Abstract: Long-term survival of cementless acetabular compo- POSTER NO. P052
nents depends on good initial stability and minimal micro-
motion at the bone-cement interface allowing rigid bone Outcomes of Limited Femoral Resurfacing for
in-growth to occur. Techniques have been developed to improve Osteonecrosis of the Femoral Head
initial stability including: use of an oversized component press- Amar D Rajadhyaksha, MD, Valhalla, NY (n)
fitted into an under-reamed acetabulum and adjuvant fixation Steven B Zelicof, MD, White Plains, NY
with screws, spikes or fins. We report the occurrence of four stress
(e – Stryker Orthopaedics)
fractures of the posterior acetabular wall resulting in disengage-
Abstract: Limited femoral resurfacing is being used for treatment
ment of the acetabular component in the early post-operative
of late stage osteonecrosis before acetabular arthritic changes
period. 1233 cases using spiked press-fit porous-coated acetab-
occur. Resurfacing may be used as a ‘time buying’ procedure to
ular components from a single surgeon series over a four year
prolong the need for total hip arthroplasty. The purpose of this
period were reviewed identifying those sustaining an acetabular
study was to report our experience with limited femoral resur-
fracture in the early post-operative period requiring revision
facing for the treatment of osteonecrosis. The clinical and radi-
surgery.All four cases are from a single surgeon series of 1233
ographic results of twenty-two limited femoral resurfacings were

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
399
PPSE 07:Layout 1 1/12/07 1:40 PM Page 400

reviewed. This study included 14 men and 8 women whose POSTER NO. P054
mean age was 37 years (range, 19 to 54). Ten patients had failed Hip Resurfacing in Avascular Necrosis (AVN)
previous core decompression. Patients with Harris Hip scores
less than 80 points at last follow up or those who were converted Versus Non-AVN: A Comparative Survival Analysis
to a total hip replacement were considered clinical failures. Ten Tajeshwar S Aulakh, MBBS, Oswestry, United Kingdom
of twenty-two hips (45 percent) were clinically successful at a (a – Smith & Nephew UK)
mean follow-up of 5.8 years (range, 24 to 82 months). Eleven Manthati Chandra Rao, MRCSEd (n)
hips were converted to total hip replacements for persistent Jan Herman Kuiper, PhD, Oswestry, Shropshire,
groin pain at a mean of 4.8 years (range, 46 to 68 months). A United Kingdom (n)
twelfth hip is awaiting conversion. Two other hips have inter-
James Bruce Richardson, PhD, Shropshire, United Kingdom
mittent groin pain but have Harris Hip Scores greater than 80.
Radiographically, there are three cases of decreased joint space (n)
when compared to immediate postoperative radiographs. Abstract: Hip resurfacing with metal-on-metal in patients with
However, these three patients remain asymptomatic. Based on avascular necrosis (AVN) raises concerns of early failure.This
these results, limited femoral resurfacing should be considered study addresses the hypothesis that AVN as a pre-operative diag-
an interim procedure for early collapsed hips prior to acetabular nosis significantly increases the risk of failure. We analysed data
involvement. Although resurfacing may prolong the need for of 3223 hips that underwent metal-on-metal hip resurfacing
total hip arthroplasty, the surgeon and patient should be aware (Birmingham Hip, Smith-Nephew, UK) at the Oswestry
of the possibility of early revision. Outcome Centre. Two groups were identified. In group 1(AVN)
were 102 hips with a pre-operative diagnosis of AVN. In group
POSTER NO. P053 2(non AVN) were 3121 hips with other diagnoses. Survival
analysis with Cox regression was used to compare the revision
Muscle Damage Following MIS Two-Incision risks of both groups. The mean age at operation was 42.5 years
Primary Total Hip Arthroplasty in group 1 and 52.9 years in group 2. The preoperative and post-
David Daniel Greenberg, MD, Columbia, MO (n) operative hip scores were 58.4 and 87.4 for group 1 and 56.8
Alan Hillard, MD (n) and 90.0 for group 2, respectively. Survival analysis with revision
Thomas Joseph Aleto, Jr MD, Columbia, MO (n) for any reason as the endpoint was performed on the two groups
B Sonny Bal, MD, Columbia, MO (c – Zimmer) which had identical follow-up periods (mean 4.8 years, range 1-
8 years). Survival at 8 years was 9
Abstract: Improved patient recovery following MIS 2-incision (2-
INC) THA may be related to decreased trauma to muscles and POSTER NO. P055
tendons. In comparison, THA with the direct lateral (DL) and
postero-lateral (PL) approaches is believed to cause more The French Paradox: Survival at a Minimal 15-year
surgical trauma. The purpose of this investigation was to Follow-up of a Polished Stem Cemented Line-to-Line
compare the MRI appearance of the hip muscles and tendons Moussa Hamadouche, MD PhD, Paris, France
following primary THA with the 2-INC, DL, and PL approaches. (e – Stryker Howmedica)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

Following IRB approval, patients with primary THA underwent

Firas El Masri, MD, Paris, France (n)
MRI scanning of the operated hip, using a metal artifact limiting
algorithm at e 18 months after surgery. This included orienting Nicolas Lefevre, MD, Paris, France (n)
the frequency encoding along the prosthesis, inversion recovery, Luc Kerboull, MD, Paris, France (n)
and a longer echo train to decrease metal artifact. Surgical Marcel Kerboull, MD, Paris Cedex 14, France (n)
approaches used were: 2-INC (n=17); PL (n=8); and DL (n=7). Jean-Pierre Courpied PhD, Paris, France (n)
Scans were read by a musculoskeletal radiologist blinded to the Abstract: The purpose of this prospective study was to evaluate the
surgical procedure. The following structures were examined for results of a polished femoral component cemented line-to-line at
muscle or tendon injury using a standard grading system: tensor a minimum 15-year follow-up. Between January 1988 and
fascia lata, gluteus maximus, gluteus medius, gluteus minimus, December 1989, 164 primary consecutive non selected total hip
piriformis, iliopsoas, sartorius, quadratus femoris, and rectus replacements were performed in 155 patients by the senior
femoris. Two patients in the 2-INC group had minimal atrophic authors. The average age at surgery was 63.7 years. A single pros-
changes of the gluteus minimus; one of these also had minimal thesis was used combining an all-polyethylene socket and a 22.2
atrophy of the gluteus medius. Each hip with the PL approach mm femoral head. The monoblock double tapered femoral
had atrophy of the gluteus medius, maximus, tensor, piriformis, component made of 316-L stainless steel had a polished surface
and quadratus femoris muscles. Each hip with the DL approach (Ra = 0.04 mm) and a quadrangular section (Kerboull® MKIII,
had atrophy of the gluteus medius, maximus, minimus, and Stryker). The femoral preparation included removal of all cancel-
tensor fascia lata muscles. Complete tendon disruptions were lous bone to obtain a primary stability of the stem prior to the
not seen in any hip. Previously reported cadaver data have line-to-line cementation. At the minimum 15-year follow-up, 73
shown that more muscle and tendon damage occur with 2-INC patients (77 hips) were still alive and had not been revised at a
THA than PL-THA. The present data suggest otherwise. At a mean of 17.3 ± 0.8 years (15-18 years), 8 patients (8 hips) had
minimum of 18 months after surgery, the MRI imaging of hip been revised for high polyethylene wear associated with periac-
muscles and tendons is nearly normal following 2-INC THA. In etabular osteolysis, 66 patients (69 hips) were deceased, and 8
contrast, PL-THA and DL-THA are associated with persistent patients (10 hips) were lost to follow-up. Among the 8 revision
atrophic changes in several muscles. These data support the procedures, the femoral component was loose in 3 cases. No other
muscle preserving advantages of 2-INC THA. femoral component was radiographically loose. The survival rate
at 17 years of the femoral component, using loosening as the end-
point, was 96.8 ± 1.8% (95% confidence interval, 93.2 to 100%).

400 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 401

This study demonstrated that line-to-line cementation of a than that in Group-B. There were no significant differences in
polished stem produced durable results with only 1.8% of average cup abduction or anteversion, but, the F-test showed
femoral components revised for loosening at 17 years. significantly larger variance of these angles in Group-B (P<0.01).
We concluded that the navigation reduces the variability of cup
POSTER NO. P056 orientation and decreases the incidence of postoperative compli-
Increased Accuracy of Acetabular Cup Placement cations such as dislocation, neck impingement notch, and
ceramic fracture after THA with the ceramic on ceramic bearing.
and Stem Placement with Imageless Computer
Navigation POSTER NO. P058
Simon Pickering, MD, Nottingham, United Kingdom Screening for Staphylococcus Aureus Does Reduce
(a – Stryker) Total Joint Surgical Site Infections
Kamal Deep, MD, Gillingham, United Kingdom Patrick G Kirk, MD, Cincinnati, OH (n)
(a – Stryker) Mary R Nicholson, RN, BSN, Cincinnati, OH (n)
Sarah Whitehouse, PhD (a – Stryker) Gina M Hissong, RN, MSN, Cincinnati, OH (n)
Ross W Crawford, MD, Brisbane, Australia (b – Stryker) Marlena Robinson, BSN, Liberty Twp, OH (n)
William A Donnelly, MD (b – Stryker) Karen Gillespie, RN, BSN, Cincinnati, OH (n)
Abstract: The aim of this control study is to definitively show the
Melissa Lewandowski, PA, West Chester, OH (n)
benefit of imageless hip navigation with regard to accuracy of cup
Abstract: In 2004, a cluster of total hip replacement surgical site
and stem position. Eighty consecutive patients were quasi-
infections (SSI) occurred at this hospital with an associated SSI
randomised to undergo conventional or navigated hip arthro-
rate of 1.47% (8/543). Five of eight deep SSIs were caused by S.
plasty. Cup and stem position was measured using CT planning
aureus. The patients and OR team members underwent nasal
software and compared to the position expected by the three oper-
cultures to rule out S. aureus colonization. Several patients along
ating surgeons in control cases and the position given by the navi-
with one staff member’s nasal culture were positive for S. aureus.
gation unit in the study group. Statistical analysis was performed
Pulse field gel electrophoresis (PFGE) typing determined the
by a statistician. 39 navigated hips and 41 control hips were
strains were not epidemiologically linked. A protocol was devel-
recruited. Groups were well matched for sex, age , pathology and
oped to identify S. aureus carriers pre-operatively and treat them
body mass index. Uncemented hips were used in 18 navigated
with intranasal mupirocin. At the time of pre-admission testing,
cases and 20 control cases, with all other cases being cemented
every patient undergoing total joint replacement surgery was
Exeter stems and contemporary cups. The mean operating time
nasally cultured. Patients identified as S. aureus carriers were
was 128 minutes for navigated hips and 84 minutes for controls
treated with mupirocin ointment twice a day for 7 days.
significant using t-test (p<0.005)Accuracy of cup and stem place-
Additionally, patients identified with methicillin resistant
ment was assessed by comparison of the homogeneity of vari-
staphylococcus aureus (MRSA) were asked to undergo a
ances, the Levene statistic, in the navigated and control groups.
chlorhexidine soap shower before surgery and were given
The range of cup inclination, cup version and stem version was
vancomycin for their surgical prophylaxis. Between December
significantly narrowed in the navigation group (p<0.05).

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

2004 and June 2006, a total of 676 total joint patients were
Computer navigation improves the accuracy of component place-
screened for S. aureus. Preoperative nasal screening cultures
ment in hip arthroplasty with respect to cup version, cup inclina-
determined a S. aureus carrier rate of 26 % (177/676). MRSA
tion and stem version with either cemented or uncemented hips
accounted for 18% of the S. aureus isolates. We observed 0 deep
POSTER NO. P057 infections over the following 19 month period (December 2004
through June 2006). Identifying and treating S. aureus carriers
Minimum Five Year Follow-Up Study of Computer with a full course of mupirocin does impact the rate of deep total
Navigation for Total Hip Arthroplasty joint S. aureus SSIs. These findings improve patient outcomes;
Nobuhiko Sugano, MD, Suita, Japan (n) decrease post-op complications, which impact hospital and
Takashi Nishii, MD, Osaka, Japan (n) patient costs. Identifying and treating S.aureus nasal carriers with
a full course of mupirocin does impact the rate of total joint
Hidenobu Miki, MD, Suita, Japan (n)
S.aureus surgical site infections. These findings improve patient
Takehito Hananouchi, MD, Suita, Japan (n) outcomes and reduce costs.
Hideki Yoshikawa, MD (n)
Abstract: Navigation has been reported to assist precise place- POSTER NO. P059
ment of cup in THA. However, its efficacy on limb length control Alumina-on-Alumina Total Hip Arthroplasty in
and mid-term clinical results has not been well documented.
The purpose of this study was to assess the med-term results of Patients with Osteonecrosis Less than 50 Years Old
THA with the use of a CT-based navigation system. One hundred Shin-Yoon Kim, MD, Daegu, Republic of Korea (n)
eighty hips in 138 patients underwent cementless THA with the Seung Hun Baek, MD, Daegu, Republic of Korea (n)
use of a ceramic on ceramic bearing (Biolox forte) with a head Seong-Man Lee, MD, Daegu, Republic of Korea (n)
diameter of 28 mm through a posterolateral approach. The navi- Abstract: The results of total hip arthroplasty (THA) in patients
gation was used in 60 hips (Group-A) and standard mechanical with osteonecrosis less than 50 years old are less durable. The
instruments were used in the remaining 120 hips (Group-B). purpose of this study was to evaluate clinical and radiologic
The patients were followed-up for 5 to 8 years (average 6.3 results of contemporary alumina-on-alumina bearing implant.
years). Seven hips experienced dislocation. Two cups were We investigated a consecutive series of alumina-on-alumina
revised due to loosening or ceramic liner fracture.Five hips THAs with a metal-backed socket and a cementless stem by the
revealed a posterior femoral neck notch. All these hips were in senior author. 68 THAs in 59 patients less than 50 years old
Group-B. Number of cases with more than 10 mm of postoper- formed our group and the patients’ age at the time of index oper-
ative limb length discrepancy in Group-A was significantly fewer ation ranged from 16 to 49(mean, 39). The mean follow-up

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
401
PPSE 07:Layout 1 1/12/07 1:40 PM Page 402

period was 7.1 years(range, 5 to 9 years). Preoperative diagnosis lated from CT data. After the method had proven its reliability,
of all the patients was osteonecrosis(idiopathic in 21 hips, we simulated ROM before and after virtual debridement and
alcohol abuse in 28, steroid induced in 11 and posttraumatic in compared it to ROM measured with a navigation system before
8). We evaluated for wear using the Livermore technique. The and after realtime surgical dislocation. 31 patients were enrolled
mean Harris hip score was 95 points at the latest follow-up. All so far for analysis. FAI-Patients had a significantly lower mean
acetabular and femoral components demonstrated radiographic flexion of 104 ± 16.1° versus 121 ± 11.8° in the control group (p
evidence of stable fixation by bony ingrowth. No ceramic wear < 0.001). Internal Rotation in 90° flexion was also significantly
and no periprosthetic osteolysis were not observed radiologi- lower (10 ± 6.8° vs. 35 ± 12°; p < 0.001). Of the 31 patients in
cally. There was no fracture of the alumina head or peripheral the sequel study, 25 hips showed impingement in the analysis
chip fracture of the alumina insert. There was no dislocation or and five patients so far had surgery following the analysis.
infection. The results of contemporary alumina-on-alumina Simulated pre- and postoperative ROM in these patients corre-
THA with a metal-backed socket and a cementless stem were lated well with the results from surgical navigation. However the
perfect at mid-term follow-up. We believe that contemporary study group is yet too small to calculate significant findings and
alumina-on-alumina bearing offer a promising option for future results have to be awaited. The identification and local-
younger, active patients with osteonecrosis of the femoral head. ization of the impingement zones and the three-dimensional
visualization may qualify our method as an accurate method of
POSTER NO. P060 recognizing FAI and facilitating preoperative planning for
Improved Shear Strength of the Bone-PMMA surgical dislocation and debridement. Prediction of benefit of
ROM shows promising results.
Interface by Vibration and Horizontal Grooves
Nakul Karkare, MD, New York, NY (n) POSTER NO. P062
Subrata Saha, PhD, Brooklyn, NY (n) Causes for Total Joint Arthroplasty Cancellations
Abstract: The objective of this study was to devise better methods
for improvement of the interfacial strength between the bone and
over Three Year Period
the cement, which might improve the longevity of cemented Wayne M Goldstein, MD, Morton Grove, IL
arthroplasties. The proximal and the distal ends of nine fresh (a, c – DePuy, Smith & Nephew, c – Innomed)
frozen bovine femora were cemented using pressurization tech- Alexander Gordon, MD, Highland Park, IL (n)
niques, vibration, and cementations after making helical grooves Jill Branson, RN, Kildeer, IL (n)
in the bone with a tap. Twenty-millimeter thick slices were then Christopher Simmons, BS, Morton Grove, IL (n)
made using a diamond saw (MK 101 series) and the shear Michelle Solari, LPN, Des Plaines, IL (n)
strength of the bone-cement interface was evaluated using push
Joanne Kern, CST (n)
out tests using an Instron mechanical testing machine. Use of
Kimberly A Berland, CST, Warrenville, IL (n)
vibration resulted in higher shear strength than pressurization
techniques. The mean shear stress for pressurized cementation, Abstract: The surgeon and office staff spend an unrecognized
vibration and of helical grooves was 0.306 ± 0.24 MPa, 1.954 ± large percentage of time preparing patients for surgery, verifying
1.47 MPa and 2.978 ± 2.49 MPa respectively for high viscosity medical clearance and insurance pre-certification. Cancellations
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

cements. A mean increase up to 537% was achieved in the inter- can disrupt the planned schedule, impact hospital productivity,
facial strength with vibration and a further 52.3% increase was and prevent other patients from more timely surgery. Over a
achieved with horizontal grooves. There was an 870% increase in three year period between 2003-2006, the surgeon author sched-
strength with horizontal grooves over pressurization for high uled 2,986 total joint arthroplasty procedures at two institutions
viscosity cements. These experiments demonstrate that grooves in (2,375-Institution A, 611-Institution B). Data was collected to
the bone and vibration improve the shear strength of bone- identify the causes for each cancellation and were categorized.
cement interface and use of these methods may reduce the inci- 24 categories were identified for the cancellation reasons.
dence of aseptic loosening after cemented arthroplasty. Institution A had a longer pre-operative window (6-8 weeks
versus 4 weeks) for their pre-operative medical clearance
POSTER NO. P061 program. This Institution also assigned a physician to all patients
of 50 years or more and required additional blood and urine lab
Femoro-Acetabular Impingement: A New work and an EKG. Stress tests were ordered for those patients
Computerized Method for 3D-Analysis and Virtual with a cardiac history, abnormal EKG and/or those 50 years or
Debridement older. During the three year period, 292 (12 percent) patient’s
surgeries were cancelled. At Institution A, 10 percent were
Timo M Ecker, MD, Boston, MA (n)
cancelled and 8 percent at Institution B. The top three reasons for
Moritz Tannast, Boston, MA (n) cancellation included: non-medical/social (n=81), cardiac issues
Stephen B Murphy, MD, Boston, MA (n) (n=64), and other medical reasons (n=54). Patients choosing to
Monika Kubiak-Langner, PhD (n) wait and cardiac issues were the top two reasons that surgeries
Frank Langlotz, PhD (n) were cancelled. In spite of the additional two weeks and labora-
Klaus Siebenrock, MD, Bern, Switzerland (n) tory tests added to the clearance process at Institution A, the
Marc Puls, PhD (n) percentage of cancellations did not improve. Patients who
Abstract: Femoro-acetabular Impingement is a major cause of choose to cancel and/or re-schedule their surgery, may not be
early osteoarthritis. A computer-assisted, non-invasive method emotionally prepared for the procedure or have social situations
has been developed to analyze hips with FAI and perform virtual that impact scheduling the procedure. Cardiac cancellations may
debridement of the joint. In a clinical pilot study we analyzed 24 remain unavoidable as long as many hospitals will not accept
patients (26 hips) with FAI against a control group of 36 patients medical clearance older than 30 days, and thus the initiation of
with normal hips. Impingement zones were detected and ROM a cardiac workup cannot be done sooner, which may identify
was simulated using a 3D model of the pelvis and femur, calcu- patients that need additional testing.

402 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 403

POSTER NO. P063 showed progression of osteoarthritis. Harris hip scores increased
Metal Ions and Oxidative Stress Markers in from 68.8 preoperatively to 91.3 at follow-up. 20 hips had an
excellent or good result, two hips a fair result and 2 hips a poor
Patients with Metal-Metal Hip Bearings result. Additional surgical procedures or a major complication
John Antoniou, MD, Montreal, Canada (a – DePuy) occurred in six hips. None of the hips have required total hip
Alain Petit, PhD, Montreal, Canada (n) replacement The PAO achieved reliable deformity correction
Fackson Mwale, PhD (n) and good early clinical results for patients with Perthes-like
David Zukor, MD, Montreal, Canada (a – Zimmer) deformities. The PAO, in combination with femoral procedures,
Olga Huk, MD, Westmount, Canada (n) has distinct advantages in treating these complex disorders.
Abstract: The purpose of the present study was to compare the POSTER NO. P065
concentrations of metal ions in blood of patients with metal-
metal (MM) resurfacing (RSA) and total hip arthroplasty (THA). The Morphology of the Femur in Femoro-
Blood was collected 6 months and 1 year after from patients Acetabular Impingement
having ASRs (n=69), 28 mm-head MM THAs (n=24), and 36 Andrew R Ellis, BS, Houston, TX (n)
mm-head MM THAs (n=53). The concentrations of cobalt (Co), Philip C Noble, PhD, Houston, TX (n)
chromium (Cr), and molybdenum (Mo) were analyzed by
Jefferey D Stimac, BS (n)
inductively coupled plasma-mass spectroscopy (ICP-MS). Since
metal ions are potent inducers of oxidative stress, total antioxi- Matthew T Thompson, BS (n)
dant, peroxide, and nitrotyrosine levels (oxidative stress Molly M Usrey, BS, Houston, TX (n)
markers) were also measured in plasma of the patients. The level John W Holden, BS (n)
of activity after 1 year (UCLA activity score) was not significantly Andrew Robert Miller, MD, White Plains, NY (n)
higher in ASR patients than in 28 mm- and 36 mm-MM THAs. Nathan Brown, BS (n)
The median Co and Cr levels progressively and significantly Gregory William Stocks, MD, Houston, TX (n)
increased in the 3 groups during the first year post-operation Abstract: Introduction: Femoro-acetabular impingement (FAI) is
(compared to patients without hip bearings (n=25)). After 6 a common source of impaired motion of the hip, often attrib-
months, the levels of Co and Cr were significantly higher in uted to the presence of an aspherical femoral head. This study
patients with ASRs and 28 mm-MM THAs than in patients with was performed to establish whether the femur, in cases of ‘cam’
36 mm-MM THAs. Levels became similar between the 3 groups impingement, has a single focal deformity or multiple abnor-
after 1 year. Mo levels were similar to those of the control group. malities of head and neck geometry contributing to reduced
Results also show no increase in oxidative stress marker levels in motion. Materials and Methods: Computer models of 30 femora
patients with ASRs and 36 mm-MM THAs and no correlations (17 normal and 13 ‘Cam’ impinging) were prepared from CT
between the concentrations of Co and Cr ions and the levels of scans. The 13 impinging cases had the distinctive appearance of
oxidative stress markers. Results show that, at short-term, the an extended head-neck junction previously reported by Ganz
concentration of ions in patients with ASRs is similar to those in and coworkers. Morphologic parameters describing the dimen-
patients with 28 mm- and 36 mm-MM THAs. Moreover, results sions of the head, neck, and medullary canal were calculated for

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

suggest that metal ions liberated from MM bearings do not each specimen. The anteversion angle, alpha angle of Notzli, and
induce damage to macromolecules by oxidative stress in plasma normalized anterior heads offset were also calculated. Average
of patients. Longer follow-ups are required to determine conclu- dimensions were compared between the normal and impinging
sively the clinical relevance of elevated circulating ions. femora. Results: Compared to the normal controls, the
impinging femora had wider necks (AP: 15.7 vs 13.0mm,
POSTER NO. P064 p=0.0001), more posterior slip of the femoral head (1.39mm vs
Periacetabular Osteotomy for the Treatment of -0.07mm, p=0.008), more vertical neck inclination (135.6 vs
Perthes-Like Deformities of the Hip 129.7 deg, p=0.02), and larger head diameters (46.2 vs 43.1mm,
p=0.03). There was no difference in neck anteversion (10.7 vs
Ryan Nunley, MD, Saint Louis, MO (n)
11.4 deg, p=0.85). As expected, the impinging femora had less
John C Clohisy, MD, Saint Louis, MO (a, e – Zimmer) anterior head/neck offset (14.3% vs 20.7% of head diameter,
Perry L Schoenecker, MD, Saint Louis, MO (n) p<0.0001), and a larger alpha angle (66.5 vs 56.0 deg, p=0.03).
Abstract: ‘Perthes-like’ deformities of the hip are characterized by The largest difference between two groups of femora was the
proximal femoral abnormalities and secondary acetabular anterior offset of the femoral neck from the head center (13.6 vs
dysplasia. The optimal method of surgical reconstruction for 9.2mm, p=0.03). Conclusions: The impinging femur differs
these complex deformities remains controversial. The purpose of from normal in terms of its AP neck width and head /neck ratio,
this study was to analyze the results of the periacetabular in addition to changes in the sphericity of the head itself.
osteotomy (PAO) in treating symptomatic Perthes-like deformi- Variations in posterior displacement of the head on the neck
ties in skeletally mature patients. We retrospectively reviewed 20 should also be appreciated when assessing morphologic factors
patients (24 hips) who underwent periacetabular osteotomy for contributing to femoro-acetabular impingement.
Perthes-like deformities. Intertrochanteric osteotomy was
performed on 14 hips to optimize the reconstruction; one had a
combined trochanteric advancement. Standard radiographic
analysis was performed and the Harris hip score was used to
assess function. The average age was 22.7 years (range, 14-34)
and average follow-up was 4.5 years (range, 2.0 to 9.3). The ante-
rior center edge angle improved an average 28.7 degrees; lateral
center edge an average 23.6 degrees; the hip joint center was
translated medially an average of 6.1 mm; and acetabular incli-
nation improved an average 15.4 degrees. At follow-up, 2 hips

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
403
PPSE 07:Layout 1 1/12/07 1:40 PM Page 404

POSTER NO. P066 mm group. The mean abduction is 27.77 and 27.98 for 28mm
Implant Retrieval Analysis: Key Lessons and 36mm groups respectively. Even though there is a slight
increase in the mean flexion and abduction from the 28mm to
Michael B Mayor, MD, Lebanon, NH 36mm group, this increase in not found to be statistically signif-
(a, e – DePuy, a – Zimmer) icant. For flexion (2.6 (-0.85 to 3.2); p=0.377), and for abduc-
Kimberly A Lyford, BA, Hanover, NH (a – DePuy, Zimmer) tion (0.02 (-2.37 to 1.94); p=0.847). Three hips dislocated in the
John P Collier, DE, Hanover, NH 28mm group (2%) but none of the hips in 36mm group has
(a, e – DePuy, a – Zimmer) dislocated. Discussion: Even though experimental studies indi-
Barbara H Currier, MChE, Hanover, NH cate improvement in range of motion with increasing head
(a – DePuy, Zimmer) diameter in THR, this effect is not reflected in our clinical study.
Douglas Van Citters, MS, Hanover, NH But there is improvement in the joint stability by using a pros-
thesis with larger head diameter as evidenced by a reduction in
(a – DePuy, Zimmer)
the dislocation rate
Abstract: Since the early 1970s, DBEC has processed 8500
retrieved orthopaedic implants. From this experience has POSTER NO. P068
emerged a set of clinically significant insights. The response of
biomaterials to patient demands reveals strengths and weak-
Complications of Total Hip Replacement with LX
nesses of both the materials themselves and the designs Prosthesis Concerns about Prosthesis Design
employed in their fabrication. Each component was examined Srinivasa Chakravarty Budithi, MS, Durham,
visually with a magnification factor from 0 to 10. The compo- United Kingdom (n)
nents were rated for clinical damage on a 0 (none) to 3 (severe) Antoni Nargol, FRCS, Stockton on Tees, United Kingdom (n)
scale. The clinical damage ratings included scratching,
Abstract: Design of the prosthesis is an important factor in the
burnishing, abrasion, fracture, pitting, cracking, delamination
successful outcome and longevity of total hip replacement. The
and defects. Metallic materials are seen to suffer scratching
purpose of the present study is to evaluate the minimum six-year
(unknown mechanism), corrosion (dissimilar metals), abrasion
results of primary total hip replacement using LX cemented
(surfaces in contact not intended), fretting (surfaces not
prosthesis. We prospectively studied 177 patients(60 male and
intended for relative motion) and fatigue (universal risk factor)
117 female) who underwent 197 hip replacements, between
in ways that directly affect the longevity of the implant system.
1996 and 1999, using LX cemented prosthesis comprising a
Polymeric materials are seen to suffer pitting (in 70-90%),
femoral component with cylindrical cross section of the stem
delamination (influenced by oxidation), cracking (related to
and an acetabular component of ultrahigh molecular weight
fatigue), and particulate release (related to intended and unin-
polyethylene. The average follow up was 7.3 years (6.1-9.6years).
tended surface motion) that directly affect the longevity of the
Clinical (Harris Hip Score) and radiological assessments
implant system. Improving patient outcomes can be directly
(Barrack’s grading of cementation, subsidence, debonding, radi-
impacted by the insights generated through formal assessment
olucent lines and osteolysis) were performed. The average Harris
of the changes wrought on these materials under patient
Hip Score is 85.53 (28-99) compared to the preoperative score
induced demands. Corrosion does occur between dissimilar
of 59.28. 28 cases(14.2%) developed progressive radiolucent
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

metals despite reassurances to the contrary. Scratching of

lines around the stem. Sinking and debonding of the stem was
metallic bearing surfaces is a surprisingly common finding. Its
noted in 18 cases(9.1%). 15 hips(7.6%) have dislocated and 11
mechanism remains unknown. Catastrophic fracture in metallic
were recurrent dislocations. Revision hip replacement was
implants reflects metallurgical, surgical and patient variables.
carried out in 12 cases (6%) for subsidence and debonding of
Polyethylene is time sensitive to degradation in ways that chal-
stem,cement fracture and recurrent dislocation. The femoral
lenge the analytical state of the art. Oxidation phenomena are a
stem components were found to be loose at the time of surgery.
key example.
We believe that design of the LX prosthesis is an important factor
POSTER NO. P067 in the high incidence of subsidence and debonding of the
femoral stem. Both the geometry (cylindrical shape) and the
Effect Of Increasing Head Diameter On The Range rough surface finish (Ra value 100 microinches) were respon-
Of Motion And Stability In Total Hip Arthroplasty sible for the pattern of progressive loosening. Lack of progressive
Srinivasa Chakravarty Budithi, MS, Durham, increase in the offset with increase in the size of femoral compo-
United Kingdom (n) nent from 1 to 2 is one of the factors which contributed to high
incidence of dislocation.
Antoni Nargol, FRCS, Stockton on Tees, United Kingdom (n)
Rajani Logishetty, FRCS, Teesside, United Kingdom (n) POSTER NO. P069
Abstract: Experimental studies in hip models indicate that larger
femoral heads offer potential in providing greater hip range of
Sensitivity of Acetabular Alignment Angles to
motion and joint stability. We studied the effects of increasing Digitizing Error in Defining Anterior Pelvic Plane
head diameter from 28mm to 36 mm in total hip replacement YeonSoo Lee, PhD, Long Beach, CA (n)
(THR) on the range of flexion and abduction 243 patients who Taek Rim Yoon, MD, Jeonnam, Republic of Korea (n)
underwent primary total hip replacement with S ROM pros- Sang Gwon Cho, MD (n)
thesis between July 1996 and June 2004 were studied. 151 Jong-Keun Seon, MD, Hwasun-eup, Republic of Korea (n)
patients (77 male and 74 female) underwent THR with 28 mm
Eun Kyoo Song, MD, Kwangju, Republic of Korea (n)
head and 92 patients (38 male and 54 female) underwent THR
with 36 mm head. The range of flexion and abduction were Abstract: During navigation assisted THA surgery, digitizing
studied and statistical analysis was performed using the Student anatomical landmarks may not be easy. This study aimed to
t-test. We monitored the dislocation rate in both groups. The provide surgeons quantitative value about the sensitivity of
mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 acetabular alignment angles resulting from digitizing error in
anterior pelvic plane (APP) based navigation system Acetabular

404 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 405

alignment angle was measured with a synthetic pelvic model, an POSTER NO. P071
acetabular alignment guide, and Orthopilot total hip navigation Comparison of Crosslinked and Older Polyethylene
system. Baseline anterior pelvic plane was defined with three
bony landmarkers, i.e. ipsilateral and contralateral anterior supe- Types in THR: An Implant Retrieval Study
rior iliac spines (ASIS), and the the center of two pubic tubercles Matias J Salineros (n)
(PC). To simulate the off-plane offset error, 1 and 2 cm cubes Roy D Crowninshield, PhD, Fort Wayne, IN (a, e – Zimmer)
were placed at the bony landmarks on the baseline APP Markus Wimmer, PhD, Davos Platz, Switzerland
Acetabular anteversion was significantly affected by any offset of (a – Zimmer)
all landmarks (p<0.05). Acetabular abduction was significantly Robin Pourzal, BS (n)
increased only by 1cm offset of ipsilateral ASIS (p<0.05). The
Jorge O Galante, MD, Clinton, WI (a, e – Zimmer)
sensitivity of acetabular anteversion was 1.8, 4.4, and -6.8
degrees/cm to the offsets of ipsilateral and contralateral ASISs, Joshua J Jacobs, MD, Chicago, IL (a, e – Zimmer)
and PC, respectively. And the sensitivity of acetabular abduction Abstract: This study documents the relative clinical performance
was 1.4, 0.2, and -0.2 degrees/cm to the offsets of ipsilateral and of three different polyethylene types supplied by one manufac-
contralateral ASISs, and PC, respectively. Current navigation turer within in a single acetabular implant system. Retrieved
system based on APP does not work as a guide for the orienta- polyethylene components from the Trilogy acetabular system
tion of acetabular anteversion. The digitization at the anterior (Zimmer Inc.) manufactured from extruded bar gamma steril-
offset of 1cm of any landmark in defining the APP can result in ized in air (group-A, eleven 28mm components averaging 49
up to 7Ú error in acetabular anteversion. Among the landmarks, months invivo in patients averaging 70 years), molded bar
the center of the two pubic tubercles brought about the greatest gamma sterilized in nitrogen (group-B, twenty three 28mm
effect on the acetabular alignment. components averaging 33 months invivo in patients averaging
61 years), and molded bar highly crosslinked (Longevity) steril-
POSTER NO. P070 ized by ethylene oxide (group-C, three 28 mm and eight 32 mm
components averaging 28 months invivo in patients averaging
The Medial Approach in Primary Total Hip 55 years). Components were visually scored for 8 potential
Replacement Surgery, a Prospective Randomized modes of surface wear or damage. Component wear and creep
Study was quantitatively accessed by comparing retrieved component
Matthias Honl, MD, Hamburg, Germany (*) head socket volume to the manufacturer’s new product specifi-
cation. The visual damage score for group-C was approximate
Matias J Salineros (*)
one half that of the other material types. Delamination was
Markus Wimmer, PhD, Davos Platz, Switzerland (*) observed only in the group-A components. Impingement
Thorsten Schwenke, Berlin, Germany (*) damage was lowest in group-C and highest in group-A.
Joshua J Jacobs, MD, Chicago, IL (*) Measured wear and creep per year invivo was 100, 64, and 10
Ekkehard Hille, MD (*) mm3 respectively for group A, B, and C (negative 13 mm3 for
Abstract: The medial approach to the hip joint is in common use 28mm group-C). Many group-C components were observed to
in the field of pediatric orthopedics; but unknown, when using have original articular surface machining marks. No cracks were

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

it for total hip replacement (THR). A prospective clinical study observed on group C. The clinical performance of three genera-
was designed to provide information regarding the differences in tions of polyethylene within a single implant system demon-
clinical outcome between a medial and conventional antero- strates progress in implant performance with the extensively
lateral approach for THR using the same prosthesis 48 patients crosslinked components demonstrating the best performance
(22 women) were randomly assigned to either the conventional despite being use in generally larger head sizes and being
antero-lateral or the medial approach implantation of a femoral implanted in younger patients.
neck prosthesis (CUT®). Harris and Oxford scores were deter-
mined pre-operatively, at three days, two weeks, six weeks, and POSTER NO. P072
six months after surgery. X-rays taken at these intervals were ◆Comparison Between Robotic and Manual Stem
analyzed for prosthesis loosening, alignment, and heterotopic
ossification. Trendelenburg sign as well as the distance a patient
Implantation of Primary THA; 3 to 5 Years Follow Up
was able to walk were determined Surgery duration was signifi- Nobuo Nakamura, MD, Osaka, Japan (n)
cantly longer in the medial approach group (p<0.001). Blood Nobuhiko Sugano, MD, Suita, Japan (n)
loss was significantly lower in the medial approach group also Takashi Nishii, MD, Osaka, Japan (n)
(p=0.009). Post-operative function scores were significantly Hidenobu Miki, MD, Suita, Japan (n)
better in the medial approach group (both p<0.001) up to six Hideki Yoshikawa, MD (n)
weeks. Trendelenburg sign and limping was significant lower in Akihiro Kakimoto, MD, Suita, Osaka, Japan (n)
the medial approach group; whereas, the walking distance was
Mitsuyoshi Yamamura, MD, Suita, Japan (n)
higher (p<0.001 for all). After six months, no differences
between the groups could be detected. There was no significantly
Daiki Iwana, MD, Osaka, Japan (n)
difference between both groups regarding the complication rate Takahiro Ochi, MD, Osaka, Japan (n)
THR via the medial skin incision increases the early clinical Abstract: The benefit of robotic-assisted stem implantation in
outcome and the cosmetic aspect. If further studies prove that primary total hip arthroplasty (THA) is still controversial. To
the risk of major complications is not higher, then the medial date, there is no clinical report beyond two years follow-up. The
approach has the potential to become commonly used purpose of this study is to compare three to five years follow-up
clinical results of robotic-assisted implantation with conven-
tional manual method and to know the safety and effectiveness
of system. We performed robot assisted primary THA for 73 hips
using ROBODOC system (Integrated Surgical Systems, Davis,
California), and conventional manual THA for 71 hips. Follow-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
405
PPSE 07:Layout 1 1/12/07 1:40 PM Page 406

up periods ranged from 36-66 months. There were no significant regions had grades in concurrence with each other. Of the
differences between two groups with regard to the patient age, differing grades, 38% were graded more severely by pathology and
gender, height, weight, and preoperative clinical scores. The 11% were graded more severely by imaging. Ten of the 45 ROIs
average surgical time was 11 minutes longer in the robotic demonstrated early changes or were normal (grades 0 ‘ 2). The
milling group (p < 0.05). In the hand-rasping group, there were average MRI grade (T1 sequence) was 2.7 +/- 1.3 and 2.2 +/- 0.8.
five intraoperative femoral fissures whereas there were no frac- The average difference between MRI and pathologic grading was
tures in the robotic milling group (p < 0.05). There were no 0.5 +/- 1.0. Initial results demonstrate good correlation between
statistical difference in intraoperative blood loss, dislocation rate pathologic and radiologic analysis of normal regions as well as for
or nerve palsy between two groups. Three years postoperatively, osteochondral defects grades 2 ‘ 4. Further refinement in sequence
Japanese Orthopedic Association (JOA) hip scores was signifi- imaging is needed for accurate evaluation of grade 1 changes.
cantly better in the robotic milling group (p<0.01). At final Since sample femoral heads can only be collected from patients
follow-up, the score was still significantly better (p<0.05). Plain who have overall severe disease and the focus of the study is on
radiographs showed bone ingrowth fixation for all the stems. early articular cartilage changes, more samples are needed to eval-
However, there were more stress shielding of proximal femur uate areas of articular cartilage that demonstrate only mild degen-
(Engh’s grade 3 or more) in the hand-rasping group than robotic eration. Overall, the more severe grading by histology suggests that
milling group (p<0.05). Robotic milling THA had less femoral further efforts should be directed at sequence optimization in
fractures, better clinical scores up to five years postoperatively, order to detect even more minute changes in articular cartilage.
and less stress shielding of the proximal femur. Subsequent correlation of proton density sequences and
pathology may prove useful in characterizing grade 1 changes.
POSTER NO. P073
Grading Articular Cartilage with MR Imaging and POSTER NO. P074
Direct Comparison with Pathologic Sections Alumina Ceramic-Ceramic Total Hip Arthroplasty:
Charles Wilson, MD, Jacksonville, FL the US-Experience from a FDA/IDE Multicenter Study
(a – University of Florida College of Medicine) Stephen B Murphy, MD, Boston, MA (e – Wright Medical)
Chris Klassen, MD Timo M Ecker, MD, Boston, MA (n)
(a – University of Florida College of Medicine) Moritz Tannast, Boston, MA (n)
Mathew Sebenik, MD Benjamin E Bierbaum, MD, Boston, MA
(a – University of Florida College of Medicine) (a – Wright Medical)
Amar Patel, MD, Cranston, RI Jonathan P Garino, MD, Philadelphia, PA
(a – University of Florida College of Medicine) (a, e – Wright Medical, e – Depuy, Smith&Nephew)
Harry Griffiths, MD, Jacksonville, FL James G Howe, MD, Burlington, VT (a – Wright Medical)
(a – University of Florida College of Medicine) Eric L Hume, MD, Wynnewood, PA (a, e – Wright Medical)
Abstract: Recent advances in MR imaging provide new opportuni- Richard Edward Jones, MD, Dallas, TX
ties to image articular cartilage with increasing detail. This study is (a – Wright Medical)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

a joint collaboration between Orthopedics, Radiology, and Kristaps J Keggi, MD, Middlebury, CT (a – Wright Medical)
Pathology departments to improve the ability of magnetic reso- Abstract: Bearing wear and osteolysis are the most common prob-
nance imaging in detecting damaged articular cartilage. Currently lems affecting the long-term results of total hip arthroplasty.
MRI can reliably identify damage only when it reaches a threshold Alumina ceramic-ceramic bearings have been introduced as one
that is greater than arthroscopy or pathologic analysis. The method of addressing these problems The current study reports
purpose of our study is to improve MR imaging of osteochondral on the 2 to 8 year results of a prospective FDA-IDE study
defects using direct pathologic comparison as a gold standard, conducted in the US. 1709 THA were performed in 1484 patients
particularly in the early stages (Grades 1-2). Seven patients under- by 22 surgeons in the US from April, 1997 to February, 2003 using
went both hip arthroplasty and a pre-operative MRI. All research alumina ceramic-ceramic bearings. Patients were studied prospec-
was conducted with IRB approval and patient consent. MRIs were tively. 1074 hips were followed for a minimum of 2 years. Survival
performed with T1, T2/Fat saturation and Proton density/Fat rate, clinical outcome and occurrence of complications were
Saturation weighting on a Philips 1.5 T. Femoral heads were investigated. Signs of osteolysis component loosening and
obtained and stored in saline until MR imaging (<24 hours). A implant wear were assessed radiographically. 8 year Kaplan-Meier
titanium rod was inserted into the femoral head as a tissue marker. Survivorship for revision of any component for loosening or
The femoral heads were scanned using the same sequences. bearing failure is 97 % (93 - 100 %). Among the 1709 THA’s, there
Regions of interest (ROIs) were identified on the images for were 18 aseptic revisions for implant related reasons, two hips
pathologic analysis. Femoral heads were then sectioned and ROIs were revised for acute and one other hip for recurrent instability.
placed in cassettes for sectioning to slides. Independent grading of Not implant related complications occurred in 21 patients. There
the articular cartilage was performed on the T1 sequence images have been no other cases of wear and no cases with osteolysis.
by a Musculoskeletal Radiologist using a 5 point scale. This scale Results from this large FDA/IDE demonstrate that the alumina
consists of; 0 (Normal), 1 (Abnormal signal), 2 (partial thickness ceramic-ceramic bearings are reliable and show very few early
<50%), 3 (partial thickness >50% but less than 100%), 4 (Full problems. Ceramic fractures do occur rarely and the incidence of
thickness cartilage loss/exposed subchondral bone). A pathologist component failure and instability is extremely low despite the
graded the corresponding ROIs from thin sections also using this absence of lipped liners and fewer head-length options. The bear-
5 point scale. Forty-five ROIs were identified that had direct ings continue to demonstrate the absence of osteolysis in this
imaging and pathologic correlation. These areas of articular carti- series of more than 8 years maximum follow-up.
lage were graded on average 3.8±1.2 by MR image and 4.3±1.2 by
pathologic grade. The average difference between MR image and
pathologic grade was negative 0.44±1.2. Fifty-one percent of

406 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 407

POSTER NO. P075 acetabular components were revised for osteolysis or loosening,
Addition of Vancomycin and Teicoplanin in Bone and 5 femoral components for osteolysis or loosening. 93% of
femoral components were bone ingrown. In addition to the
Cement: Effect on Mechanical Properties revised cases, 4 acetabular components had migrated. Minor
Kleovoulos S Anagnostidis, MD (n) distal osteolysis only occurred around 4 femoral implants,
Nikolaos Michailidis, PhD (n) however acetabular osteolysis occurred around 30 acetabular
George Mesomeris, PhD (n) components. 10% of living patients (4 hips) had some thigh
Konstantinos D Bouzakis, PhD (n) pain, but no hip was revised for thigh pain. Although the acetab-
John M Kirkos, MD, Thessaloniki, Greece (n) ular results with the PCA have not been comparable to other
cementless devices of its generation (probably related to 32 mm
George A Kapetanos, MD, Thessaloniki, Greece (n)
heads), the femoral results have been durable with only 2%
Abstract: Infections with multiresistant bacteria have become a revised for loosening and 5% revised overall (probably related to
serious problem in joint arthroplasty. Vancomycin and the circumferential coating and initial stability if proper sizing
Teicoplanin showed high effectiveness against multiresistant was performed). In addition, the durability of this cementless
bacteria as methicillin-resistant S.epidermidis (MRSE) and femoral fixation is at least as good as that reported with cement
methicillin-resistant S.aureus(MRSA). The purpose of the at this length of follow-up.
present study was to compare the mechanical properties of
powdered vancomycin and teicoplanin in acrylic bone cement. POSTER NO. P077
Standardized specimens consisting of Palacos R-40 cement
combined with 1000mg powdered vancomycin and 400mg
Midterm Survival of the Pinnacle Multi-Liner
powdered teicoplanin were prepared using the third generation Acetabular Cup in a Prospective Multi-Center Study
cementing technique. The two groups were tested with regard to Kirk Kindsfater, MD, Fort Collins, CO
compression strength, and fatigue strength. In order to examine (a, e – DePuy Orthopaedics, Inc.)
the mechanical properties of the specimens, impact and William P Barrett, MD, Renton, WA
compression tests were applied. The impact test is a well-estab-
(a, c, e – DePuy Orthopaedics, Inc.)
lished method for the characterization of materials’ fatigue prop-
erties, as well as of creep behavior determination in case of James E Dowd, MD, Virginia Beach, VA
porous materials. The size of the produced impression after a (e – DePuy Orthopaedics, Inc.)
certain number of impacts reveals the material strength. Carleton Southworth, MS, Warsaw, IN
Furthermore, the compression resistance, i.e. the Young’s (e – DePuy Orthopaedics, Inc.)
modulus and the yield strength are properties that can be calcu- Marilyn J Cassell, RN, Warsaw, IN
lated by the compression tests. The compression tests showed (e – DePuy Orthopaedics, Inc.)
that the specimens containing teicoplanin had overall better Abstract: A single acetabular system that accommodates a variety
mechanical properties, having approximately 12% higher of liner and head size options can be advantageous in total hip
Young’s modulus than the specimens containing vancomycin. arthroplasty. Between July 2000 and April 2006, 1,183 consecu-
The impact test revealed a corresponding tendency, with the tive primary Pinnacle acetabular cups were implanted by 16

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

specimens containing 400mg of teicoplanin having the smaller surgeons, in a prospective non-randomized study. Nine different
impression (increased fatigue strength) when compared with cemented and uncemented stems were used. Bearings were 2%
specimens containing 1000mg vancomycin. The experimental ceramic-on-polyethylene, 35% metal-on-metal, and 63% metal-
data showed that the addition of 400mg teicoplanin in Palacos on-polyethylene. Non-inflammatory disease was the primary
R-40 had better mechanical properties compared with addition diagnosis in 98% of hips. Mean age was 62 years (range 18 to
of 1000mg vancomycin. 92), and 622 patients were female. Mean weight was 188
pounds (range 89 to 370); mean height, 67 inches (range 49 to
POSTER NO. P076 79); and mean Harris Hip Score at 24+ months was 95. Average
Was the PCA THR that Bad? Minimum 20 Year follow-up was 24 months. At 5 years, acetabular cup survival was
Outcome of Primary PCA Cementless Total Hip 99.9% (Kaplan-Meier, lower 95% confidence interval = 99.6%).
Sixteen hips dislocated. Of these 16 dislocations, one cup was
Arthroplasty revised for instability at 2 weeks post-op. Ten hips underwent
John J Callaghan, MD, Iowa City, IA (a, c, e – DePuy) reoperations where a stable cup was retained, 5 hips were treated
John S Xenos, MD, Colorado Springs, CO (n) conservatively. Eleven additional re-operations were required:
Steve S Liu, MD, Iowa City, IA (n) hematoma (4), femoral fracture (3), stem loosening (2), super-
Carlton G Savory, MD, FACS, Columbus, GA (n) ficial infection (1), and modulus mismatch (1). This acetabular
Abstract: There were initial concerns reported with the PCA cup system demonstrated outstanding mid-term survival.
cementless total hip replacement to include bead shedding, radi- Differences between patients, surgeons, stem, head size, and
olucent lines around the device, and thigh pain. This study articulation type did not affect survival. Reoperation for insta-
addresses the question ‘What is the durability of cementless PCA bility in the current series was aided by an acetabular system that
total hip arthroplasty at minimum 20 year follow-up?’ 100 accommodates a variety of liner and head size options. Ten of 11
consecutive PCA cementless total hip replacements were reoperations for dislocation were able to be treated with reten-
inserted in 91 patients between October 1983 and January 1986. tion of the stable acetabular component and increased liner
The average age at surgery was 58 years. Patients were prospec- offset, femoral head diameter or both.
tively evaluated for clinical results (Harris Hip Scores) as well as
the need for femoral or acetabular revision, migration or subsi-
dence of the components, and osteolysis at 5 year intervals in all
cases. At minimum 20 year follow-up, 37 patients with 42 hips
were living and 54 patients with 58 hips were deceased. Twenty

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
407
PPSE 07:Layout 1 1/12/07 1:40 PM Page 408

POSTER NO. P078 aggressive regimen. The demographic distribution amongst all
The Accuracy of Imageless Computer Navigation in the groups was similar. There was a significant improvement in
function as measured by Harris Hip Score, LASA (validated reha-
the Placement of the Birmingham Hip Resurfacing bilitation score), SF-36, and lower extremity function test in all
Edward T Davis, FRCS, Brimingham, United Kingdom groups. The extent of functional improvement, home discharge,
(a, b – Smith&Nephew) patient satisfaction, and analgesia requirement was better in
Price Gallie, FRACS (a, b – Smith&Nephew) patients who received aggressive preoperative and postoperative
Kelly MacGroarty, FRACS (a, b – Smith&Nephew) care regimen regardless of the size of their incision. There was no
James P Waddell, MD, Toronto, Canada difference in estimated blood loss, mean operative time, trans-
fusion needs, and complications between the groups. This study
(a, e – Smith&Nephew)
highlights the importance of family education, patient condi-
Emil H Schemitsch, MD, Toronto, Canada tioning, pre-emptive analgesia, and aggressive preoperative and
(a – Smith&Nephew) postoperative rehabilitation in influencing the outcome of THA.
Abstract: Alignment of the femoral component in the coronal The aforementioned factors, and perhaps not the surgical tech-
plane has been found to impact on survivorship following hip nique per se, may play a major role in imparting advantageous
resurfacing. We aimed to assess the accuracy of an imageless outcome to MIS THA that is reported by various investigators.
computer navigation system in positioning the Birmingham Hip
Resurfacing femoral component. Six pairs of cadaveric limbs were POSTER NO. P080
randomized to the use of computer navigation or standard Poor Eight Year Survival of Second Generation
instrumentation for the placement of the Birmingham Hip
Resurfacing femoral component. All hips had radiographs taken Metal-on-Metal Cemented Total Hip Arthroplasty
prior to the procedure to facilitate accurate templating. All Jean Yves Lazennec, MD, Paris, France (n)
femoral components were planned to be implanted with a stem Patrick J Boyer, MD, Boston, MA (n)
shaft angle of 135 degrees. The initial guide wire was placed using Marc Antoine Rousseau, San Francisco, CA (n)
either the standard jig or with the use of an imageless computer Frederic Laude, MD (n)
navigation system. The femoral head was then prepared in the Yves Catonne, MD, Paris, France (n)
same fashion for both groups. Following the procedure radi-
Gerard Saillant, MD, Paris, France (n)
ographs were taken to assess the alignment of the femoral
component The mean stem shaft angle in the computer naviga- Abstract: Improvements of the cobalt chrome alloy and refine-
tion group was 133.3 degrees compared to 127.7 degrees in the ment of the articular surfaces characterize the second generation
standard instrumentation group (p equals 0.03). The standard of metal-on-metal tota hip arthroplasty (THA). Some recent
instrumentation group had a range of error of 15 degrees with a studies report unexpected findings with these implants. The goal
standard deviation of 4.2 degrees. The computer navigated group of this paper is to present our own experience regarding Metasul
had a range of error of only 8 degrees with a standard deviation bearing surfaces in cimented THA. Our first 97 consecutive THA
of 2.9 degrees. Computer navigation was more accurate and with Metasul bearing surfaces (76 patients) were prospectively
more consistent in its placement of the femoral component followed at 3, 6 months, and every year thereafter. In addition
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

when compared to standard instrumentation. We suggest that Co, Cr, Ti serum levels were dosed at the same intervals. The
imageless computer navigation may improve the accuracy of smooth titanium stem and the Weber socket were both
alignment of the femoral component during hip resurfacing. cemented. The femoral head was 28 mm in diameter with a
12/14 morse taper. The mean age at the time of surgery was 54
POSTER NO. P079 years. The mean follow-up was 8 years (5-12). 2 cases had early
revision for recurrent dislocation (neck impingement associated
Minimally Invasive Hip Arthroplasty: What Other with increased titanium, Co and Cr serum levels). 7 THA under-
Factors Play A Role? went revision for painful wide osteolysis (5 cases), and major
Aidin Eslam Pour, MD, Philadelphia, PA (n) radiological osteolysis (2 cases). Osteolysis was always located
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) on the acetabular side. At the time of revision, important macro-
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker) scopic metallosis was noted in 4 cases. In addition, 3 more revi-
sions are scheduled for severe and evolutive osteoysis. 30 other
William J Hozack, MD, Philadelphia, PA (e – Stryker)
hips show evolutive acetabular radiolucent lines, and 8 cases had
Richard H Rothman, MD, Philadelphia, PA (e - Stryker) limited proximal femoral radiolucencies. Titanium release from
Abstract: The potential benefits of Minimally invasive total hip the stem was always under the detection limit; but serum Co and
arthroplasty (MIS THA) continues to be heavily debated. We Cr levels were significantly increased in the revision cases and for
hypothesized that the potential benefits of MIS THA may relate the worrisome THA. The rate of early alteration of the acetabular
to factors such as patient selection, patient preconditioning, site raises significant concerns. Metallosis, acetabular osteolysis,
improvements in anesthesia technique, pain management, and as well as the increase of Co Cr serum levels make us doubt
not the incision size. This randomized, prospective study was about cemented second generation metal-on-metal THA.
designed to investigate the role of these confounding factors in
general and aggressive rehabilitation in particular on the
outcome of THA. 100 patients undergoing THA at our institu-
tion were randomized into one of four groups. Group A was
patients who had standard THA (incision length>10 cm) and
received standard preoperative and postoperative care. Group B
patients had THA using small incision (<10 cm) and standard
protocols. Group C patients had regular incision THA, but
received aggressive rehabilitation and pain control regimen.
Group D patients had THA through small incision and received

408 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 409

POSTER NO. P081 trochanters. The x-ray magnification was normalized using the
Validation of a New Method for Standardized known diameter of the acetabular component. Compared to radi-
ographic leg-length change, the simplified computer’assisted
Evaluation of Anteroposterior Pelvic Radiographs method had a mean difference of -0.19 mm ± 1.59 (range -3.4 to
Moritz Tannast, Boston, MA (a – NCCR Co-Me and 3.9 mm) There was no statistically significant difference between
fellowship of the Swiss National Science Foundation) radiographic data and the navigation data [p-value = 0.723]. The
Sapan Mistry, MD (n) current simplified method of measuring leg-length changes during
Mario Arduini, MD (n) surgery appears to be accurate and efficient. It is likely that this
Li Zheng, MD, PhD (n) methodology will apply equally as well to image-free navigation
and to any other image-based navigation. The addition of more
Frank Langlotz, PhD (a – NCCR Co-Me of the Swiss
procedures will improve our assessment of this simplified method
National Science Foundation) of measuring leg-length change during surgery.
Klaus Siebenrock, MD, Bern, Switzerland (a – NCCR
Co-Me of the Swiss National Science Foundation) POSTER NO. P083
Abstract: Correct interpretation of the acetabular rim is crucial for Total Hip Replacement and Ease of Care Using
diagnosis of pathoanatomical hip abnormalities such as
dysplasia or femoroacetabular impingement. Individual pelvic
Fentanyl Iontophoretic Transdermal System Versus
tilt and rotation can drastically affect the appearance of the IV PCA
acetabular contour on anteroposterior (ap) pelvic radiographs, Michael H Bourne, MD, Salt Lake City, UT (b – Bourne)
including features as acetabular retroversion or the more classical Abstract: The patient-controlled fentanyl HCl iontophoretic trans-
lateral center edge angle. The aim of the study was to evaluate the dermal system (ITS) is a compact, preprogrammed analgesic
performance of specifically developed software for tilt and rota- delivery system recently approved by the FDA for the management
tion correction of the acetabular rim and associated radiographic of acute postoperative pain. Fentanyl ITS was shown to produce
parameters. Validation comprised three steps: (1) External vali- comparable pain control to morphine intravenous patient-
dation; (2) internal validation; and (3) intra-/interobserver controlled analgesia (IV PCA). This pooled analysis compared the
analysis. A total of 30 cadaver hips and 100 randomized, blinded ease of care (EOC) for patients and their physical therapists (PTs)
ap pelvic radiographs of a consecutive patient series were used for between the 2 modalities. Data were pooled from 2 randomized
evaluation. External validation comprised the comparison of studies evaluating fentanyl ITS versus morphine IV PCA for acute
femoral head coverage determined with our software with CT- postoperative pain management following unilateral total hip
based measurements as gold standard as well as the comparison replacement. Validated EOC Questionnaires were completed by
of conventional radiographic hip parameters for a neutral orien- patients and their PTs with scores calculated using a 6-point Likert
tation. Internal validation calculated differences among the scale. Overall patient EOC scores were based on several subscales
different parameters for each cadaver pelvis when reckoned back including Movement and Confidence with Device. Overall PT
from a random to the neutral orientation. Intra-/interobserver EOC scores were calculated from 2 subscales: Time-Consuming
analyzed the reliability and reproducibility of all (femoral and (measuring time-efficiency) and Bothersome (measuring conven-
acetabular) parameters. The software could be shown to be an

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

ience). Compared with patients receiving morphine IV PCA, a
accurate, reliable and reproducible method for correction of significantly greater number of patients receiving fentanyl ITS
anteroposterior pelvic radiographs. A detailed list for each vali- responded with the 3 most positive responses for overall EOC
dation step will be presented for all 25 evaluated radiographic (42.0% vs 28.2%; P<0.001), Movement (97.4% vs 72.1%;
features. This computer-assisted method allows standardized P<0.001), and Confidence with Device (91.8% vs 82.4%;
evaluation of all relevant radiographic parameters for evaluation P<0.001). A significantly larger number of PTs responded with the
anatomic morphologic differences, making their clinical rele- 3 most positive responses for fentanyl ITS versus morphine IV
vance for development of early osteoarthritis more valuable. PCA for overall EOC (83.8% vs 56.7%; P<0.001) and the time-
efficiency (85.9% vs 60.8%; P<0.001) and convenience (87.3% vs
POSTER NO. P082 71.6%; P<0.001) subscales. Compared with IV PCA, fentanyl ITS
Introduction of a New Computer-assisted Method is associated with better patient and PT EOC, and in particular,
of Intraoperative Leg Length Measurement in THA better patient mobility in a postoperative setting.
Stephen B Murphy, MD, Boston, MA (n) POSTER NO. P084
Timo M Ecker, MD, Boston, MA (n)
Abstract: Leg length inequality is a major source of dysfunction and
Human Autopsy Retrieved Hip Replacements
dissatisfaction following THA. Two prior computer-assisted Evaluated with Electron Microscopy
methods of measuring leg-length change during surgery have had D Kevin Lester, MD, Fresno, CA (n)
significant problems. To address these problems, a method was Abstract: Senior age and sinescent bone is considered a
developed where the femoral reference frame is tracked in the contraindication to cementless femoral implantiion due to the
pelvic coordinate system before and after reconstruction. 84 expectation of inadequate osteogenic potential. Despite the
patients underwent CT-based computer-assisted THA with the new known risks of cement most orthopedists use cement in elderly
leg-length measurement algorithm and using a tissue-preserving patients for fixation. Back scattered electron microscopy was
approach through a superior capsulotomy. Pelvic and femoral used to evaluate the bone-prothesis interface in 6 autopsy
skeletal reference frames were applied and the leg was placed in a retrieved cementless femoral implants. Each implant was tita-
clinically neutral and straight position. Leg-length changes were nium with a grit blast surface. The patients average age was 79
then quantified by measuring the leg-length discrepancies on the years with average time in situ 24 months. Viable remodeling
post-operative and pre-operative x-rays. This was achieved by bone is notable at the bone-implant interface in each case.
drawing a horizontal line between the tear drops and then meas- Electron microscopic images are available for each case. Cross
uring down orthogonally to the most proximal points on the lesser section radiograph and micrographs are also available.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
409
PPSE 07:Layout 1 1/12/07 1:40 PM Page 410

Qualitative anaylsis indicates that senior age and sinescent bone retrospectively reviewed 730 hips treated with primary THA for
condition do not preclude osseointegration. Quantitative advanced joint disease in patients d50 years. Standard radi-
analysis is available in cross section radiographic and micro- ographic criteria were utilized to characterize the acetabular and
scopic preparations. They compare satisfactorily to those of proximal femoral anatomy. Hips were classified by radiographic
beaded and sintered metal ingrowth studies. Cementless diagnoses and structural abnormalities. 54% of 730 hips were in
femoral implantation is effective in senior patients despite male patients, 46% in females and the average age was 40.2 years.
osteoporosis. The risks of cement can be avoided and satisfactory 220 (30.1%) had osteonecrosis, 48 (6.6%) had posttraumatic
osseointegration can be expected. disease, 37 (5.1%) had inflammatory arthritis, 405 (55.5%) had
osteoarthritis and 20 (2.7%) were missing pre-operative radi-
POSTER NO. P085 ographic data. Of these 405 osteoarthritic hips, 181 had classic
Total Hip Arthroplasty Less Painful at 12 Months in DDH, 32 Perthes, 21 SCFE and 171 OA of unknown etiology. A
comprehensive radiographic analysis was then performed on the
the Treatment of Displaced Femoral Neck Fractures 171 hips without a known etiology. Within this group 78 had
William Macaulay, MD, New York, NY (a – OREF) radiographic findings consistent with cam impingement
Kate Nellans, New York, NY (n) (reduced head-neck offset, aspherical femoral head), 10 with
Kevin L Garvin, MD, Omaha, NE (n) pincer impingement (retroversion or coxa profunda/protrusion)
Richard Iorio, MD, Burlington, MA (n) and 40 with a combined cam/pincer impingement disorder. 6
William L Healy, MD, Burlington, MA (n) hips had septic etiology and 37 had no obvious structural abnor-
Richard S Yoon, BS (n) mality or disease too advanced to determined. This study demon-
strates a high incidence of structural deformities in a large group
Jeffrey Geller, MD, New York, NY (n)
of patients with premature failure of the hip. Radiographic
Melvin Paul Rosenwasser, MD, New York, NY (n) abnormalities consistent with impingement disease were the
Abstract: The Displaced Femoral (neck fracture) Arthroplasty most common findings in the osteoarthritic hips.
Consortium for Treatment and Outcomes (DFACTO) study is a
prospective, randomized multi-center clinical trial comparing POSTER NO. P087
total hip arthroplasty (THA) to hemiarthroplasty in the treatment
of displaced femoral neck fractures to examine alternative surgical
Osteolysis with Highly Crosslinked and Non
options to improve outcomes. Functional outcomes and quality Crosslinked Polyethylene at Minimum 5-Year
of life were measured at follow-up visits at 6 and 12 post-fracture Follow-Up
using the SF-36, Western Ontario and McMaster University
Serena B Leung, Alexandria, VA
Osteoarthritis Index (WOMAC), the Harris Hip Score, and the
(a – Inova Health Care Services, Depuy)
Time ‘Up & Go’ Test. Forty subjects were enrolled. Groups were
equivalent at baseline in terms of age, co-morbid conditions, and Adam Stepniewski, MD, Wroclaw, Poland
functional status. At 6 months, there were no significant differ- (a – Inova Health Care Services, DePuy)
ences between the groups using the outcome measures or overall Hiroshi Egawa, MD, Alexandria, VA
rates of complications. There was one dislocation in the THA (a – Inova Health Care Services, DePuy)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

group (5.8% of patients) with relatively no other complications. C Anderson Engh Jr, MD, Alexandria, VA (c, e – DePuy)
At 12 months, the THA group reported significantly less pain Charles A Engh Sr, MD, Alexandria, VA (c, d, e – DePuy)
(53.2±10.2) than the hemiarthroplasty group (42.4±11.5) using Abstract: In both laboratory and clinical studies, crosslinked
the SF-36 (p=0.02). We also saw a general trend towards better polyethylene has shown decreased wear rates, but the effect on
scores in the THA group in other SF-36 sub-scales, as well as the osteolysis still needs to be examined. This study sought to deter-
WOMAC and Harris Hip Score, though not statistically significant. mine if the incidence and volume of pelvic osteolysis decreased
Early differences in pain, without significantly greater incidence of with use of a crosslinked polyethylene. CT more accurately
complications, suggest THA is a valuable treatment option for the measures volume than radiographs and can detect small lesions
active elderly hip fracture population. We will continue to follow making it useful for the early detection of pelvic osteolysis. 230
these subjects through 24 months to determine if differences in hips were randomized to a Marathon crosslinked (Depuy) or
pain between the groups at 1 year will translate into diverging Enduron non crosslinked (Depuy) 4-mm lateralized polyeth-
functional outcomes. ylene between 1999 and 2000 in an IRB-approved prospective
study separate from this study. 76 study hips received a
POSTER NO. P086 computed tomography (CT) scan as part of routine clinical
Morphologic Features of Hips in THA Patients Age follow-up. CT scans were analyzed using a validated post-
50 and Under processing software packaged (Muscular-Skeleton Analysis
Software) that allowed a blinded observer to define osteolysis
John J Callaghan, MD, Iowa City, IA (a, c, e – DePuy)
and determine osteolysis volume. The average length of follow-
John C Clohisy, MD, Saint Louis, MO (n) up was 6.1 ± 0.4 years. 36 hips had a Marathon polyethylene and
Tameem Yehyawi, BS (n) 40 had an Enduron polyethylene. There were 12 (30.0%)
Lucian Warth, BS (n) Enduron and 6 (16.7%) Marathon cases with at least one oste-
Steve S Liu, MD, Iowa City, IA (n) olytic lesion. There was no significant difference (p = 0.19) in the
Abstract: Recent advances in the understanding of the pathome- incidence of osteolysis between the two groups. The average
chanics and pathoanatomy associated with secondary hip lesion volume for Enduron cases was 7.0 ± 6.7 cm3, which was
osteoarthritis have broadened the scope of joint preserving significantly larger (p = 0.001) than the average lesion volume
surgery. Nevertheless, the specific disease patterns associated with for Marathon cases of 1.2 ± 0.7 cm3. At this short follow-up
early hip degeneration are not completely understood. The interval, Marathon crosslinked polyethylene has shown to have
purpose of this study was to characterize structural disorders of a decreased volume of pelvic osteolysis over Enduron non
the hip associated with premature secondary osteoarthritis. We crosslinked polyethylene. Longer follow-up is necessary to deter-

410 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 411

mine if Marathon crosslinked polyethylene will continue to with 59 hips (54 patients) meeting our criteria. Of these, 7 hips
demonstrate the encouraging improved wear and osteolysis had documented revision and 2 hips had failed radiographically.
characteristics found in both the literature and the current study. Patients returned for a 15-20 year followup, including physical
examination, Harris Hip scores, SF-36 scores, and radiographs.
POSTER NO. P088 The average Harris Hip score was 82.3. Radiographically, 12 hips
Bipolar Proximal Femoral Replacement Prostheses demonstrated eccentric wear, 8 had osteolysis, and 1 had a
broken tine. Two hips required revision, 1 for a loose femoral
For Musculoskeletal Neoplasms component and 1 for severe wear. Of those hips with immediate
Richard D Lackman, MD, Philadelphia, PA postoperative films available, the mean polyethylene wear rate
(e – Stryker Howmedica) using 2-D analysis was calculated to be 0.134 mm/year. For the 9
Edward J Fox, MD, Philadelphia, PA (n) hips that failed, the average time to failure was 12.25 years. Five
Joseph L Finstein, MD, Philadelphia, PA had a loose femoral component, 3 had severe wear, and 1 was
(a – Stryker Howmedica) infected. At a mean of 17 years after surgery, survivorship was 77
Joseph J King, MD, Monroe, NC (a – Stryker Howmedica) percent with a polyethylene wear rate similar to that of cemented
THA. These numbers are promising for a procedure that has
Christian Ogilvie, MD, Merion Station, PA (n)
become one of the most common forms of implantation.
Abstract: Bipolar prostheses are used both to treat muscu-
loskeletal neoplasms and for nontumor indications. We hypoth- POSTER NO. P090
esize that bipolar proximal femoral replacement prostheses
(PFRPs) for tumor indications will have a higher complication Highly Polishing All Double-Tapered Femoral Stems
and revision rate but a similar rate of groin pain and conversion is Unnecessary
to THA for acetabular wear when compared to nontumor indi- Sophia Sangiorgio, MSc, Los Angeles, CA (a – Zimmer)
cation literature. 62/67consecutive patients retrospectively iden- Edward Ebramzadeh, PhD, Los Angeles, CA (a – Zimmer)
tified from a surgical case list (mean follow-up=5.0years)
Donald B Longjohn, MD, Torrance, CA
received PFRPs from 1984-2003 and met inclusion criteria. Only
(e – Zimmer, consultant)
PFRPs performed for primary oncologic or revision of internal
fixation for tumors were included. Both tumor patients and Lawrence D Dorr, MD, Inglewood, CA
nontumor historical controls received bipolar hemiarthroplasty (e – Zimmer, consultant)
with a cemented fixed diaphyseal stem. 32men and 30women Abstract: It is well-publicized that the double-tapered Exeter stem,
had a mean age of 49years at PFRP surgery. 33 patients received successful when highly polished, performed poorly with a matte
adjuvant radiation therapy, 42received chemotherapy and surface finish. Surprisingly, comparable changes in surface finish
25had both. Operative data including specific surgical, onco- have had no effect on clinical outcome of similar double-tapered
logic, and outcome information was collected. 9.7%(6/62) stems such as the MS-30. As the Exeter and the MS-30 differ
needed revision for symptomatic femoral loosening versus 2.4% primarily by the presence of an additional dimension of taper or,
(5/212, Haidukewych) for nontumor (p=0.002). 19.4% (12/62) rather, the presence of proximal dorsal flares on the MS-30, this
of PFRPs needed a revision versus 5% (10/212, Haidukewych) in difference is clearly of clinical significance. Therefore, we evaluated

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

bipolars for nontumor indications (p=0.0007). Only 2% (1/62) the stability of four otherwise identical versions of the MS-30: (1)
of patients had groin pain versus 11% (3/28) in Chan’s polished with flares, (2) polished without flares, (3) matte with
nontumor bipolar series (p= 0.09). None were converted to THA flares, and (4) matte without flares. Femoral stability was meas-
as a result of acetabular erosion versus 1 (Chan). 4/62 (7%) ured at both interfaces, in three planes, under cyclic load and
patients had local tumor recurrence. The overall limb salvage torque, with a separate dynamic muscle force, simulating walking
rate was 98.4%. The event-free prosthetic survival was 85% at 2 and stair-climbing. Two loading conditions were simulated: (1)
years and 79% at 5 years. PFRPs for tumors have a higher revi- sixteen with intact interfaces simulating immediate post-operative
sion and complication rate than nontumor series, but less groin conditions, (2) sixteen with stems initially debonded from
pain and a similar THA conversion rate. cement, simulating conditions several months post-op when
fibrous tissue forms. The results indicated that for double-tapered
POSTER NO. P089 stems, the presence of dorsal flares, regardless of surface finish and
15 to 20 Year Results of Cementless Harris-Galante I bonding conditions, improved initial axial stability by 22µm per-
cycle at the stem-cement interface (P<0.05) and early migration by
and II Acetabular and Porous Femoral Components as much as 200µm. In contrast, surface finish had very little effect.
Scott Anseth, MD, Edina, MN (b – Biomet, Sanofi Aventis) The presence or lack of dorsal flares is more important to the
Shantanu Patil, MS, La Jolla, CA stability of a double-tapered stem than surface finish. These find-
(b – Biomet, Sanofi Aventis) ings explain the clinical success of the matte-finish MS-30, as
Pamela A Pulido, RN, BSN, La Jolla, CA compared to the clinical failure of the matte-finish Exeter.
(b – Biomet, Sanofi Aventis)
POSTER NO. P091
Julie C Sandwell, MPH (b – Biomet, Sanofi Aventis)
Clifford W Colwell Jr, MD, La Jolla, CA A Two-Stage Approach to Cementless Hip
(b – Biomet, Sanofi Aventis) Arthroplasty in the Infected Arthritic Hip
Abstract: The long-term results of cementless total hip arthro- David George Nazarian, MD, Philadelphia, PA
plasty (THA) are still unclear. This study examined the long-term (a, c, e – Zimmer)
survivorship, timeframe for failure, and reasons for revision Hari Bezwada, MD, Philadelphia, PA (e – Zimmer)
arthroplasty of the Harris-Galante implant. Using our outcomes Robert E. Booth, Jr MD, Philadelphia, PA (a, e – Zimmer)
database, with IRB approval, patients who underwent THA
Abstract: Septic arthritis or chronic osteomyelitis of the arthritic
between 1985 and 1990 using Harris-Galante I or II acetabular
hip has traditionally been considered a contraindication to total
and Harris-Galante porous femoral components were identified
hip arthroplasty. This study is a review of a consecutive series of

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
411
PPSE 07:Layout 1 1/12/07 1:40 PM Page 412

infected native hips, which were treated with a cementless hip POSTER NO. P093
arthroplasty after placement of an interval antibiotic impregnated Effects of Acetabular Component Position on Cup
cemented arthroplasty. Six hips were treated between 1996 and
2003 for recurrent septic arthritis or chronic osteomyelitis. All Wear Rates in Total Hip Arthroplasty
patients underwent radical soft tissue debridement, femoral and Lawrence D Dorr, MD, Inglewood, CA (a, c – Zimmer)
acetabular preparation for cemented hip arthroplasty with an all Zhinian Wan, MD, Inglewood, CA (n)
polyethylene socket, and a cemented CDH stem. Patients were Myriam Boutary, Burbank, CA (n)
treated with IV antibiotics for 6 weeks and were reimplanted no Abstract: Introduction: Polyethylene wear is influenced by
less than 3 months (avg 3.8 months) after the index procedure. multiple factors: patient-related factors, implant-related factors,
Patients were evaluated radiographically and clinically using a and surgery-related factors. The relationship between polyeth-
modified Harris Hip Score. All patients had severe pain and ylene wear and implant position is controversy in laboratory and
disability prior to the index procedure. The average preoperative clinical studies. The purpose of this study was to test whether
hip score was 47 and postoperative score was 86 at an average acetabular component position affects the polyethylene wear
follow up of 6.7 years (range 3-10). All patients had good or after total hip arthroplasty. Methods: We analyzed radiographic
excellent pain relief with no evidence of recurrent infection. There wear data on 139 total hip arthroplasties after a mean duration
were no cases of fracture, loosening, or dislocation. Treatment of follow up of 9.2 years (range, six to thirteen years). 49 of 139
alternatives for recurrent sepsis of the arthritic hip have generally hips had an operated and non-operated hip and these could be
been unsatisfactory. Arthroscopy or open debridement has compared for center of rotation (COR). Measurements
limited amative potential in the chronically infected hip. performed were acetabular component orientation, COR, and
Arthrodesis or resection arthroplasty may be amative, but present relationships of cup to bony landmarks on the AP pelvic radi-
significant functional limitations. Although primary arthroplasty ographs. Results: The multiple regression model accounted for
is contraindicated in the actively infected hip, this study reports 21.5% of the variation in the polyethylene wear rate data
on a successful treatment protocol which provides excellent func- (r2=0.215). The following variables were significantly correlated
tional results with clinical eradication of periarticular infection. with increased polyethylene wear: male gender (p=0.022),
patients younger in age (p=0.005), metal head (p=0.012)
POSTER NO. P092 (ceramic head had a smaller wear rate), and larger inclination
Computer Navigation For Accurate Acetabular angles (p<0.0005). Location of the center of rotation of the hip,
Reconstruction In Revision Hip Surgery anteversion of the acetabular component, leg length, and
femoral offset did not statistically affect polyethylene wear.
Aamer Malik, MD, Inglewood, CA (n)
Conclusion: Acetabular inclination is statistically weakly related
William T Long, MD, Inglewood, CA (n) to polyethylene wear (only 6% of the variability in wear is
Lawrence D Dorr, MD, Inglewood, CA (a, c – Zimmer) explained by inclination); COR and anteversion were not
Zhinian Wan, MD, Inglewood, CA (n) related. Technically, it is better to have inclination near 40
Abstract: Introduction Component position influences long term degrees by medialization and superior positioning of the cup
survival of joint reconstruction through wear, impingement, (for coverage) rather than compulsive maintenance of the COR.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

dislocation etc. This is even more important in the revision

setting where bone loss, previous component position and poor POSTER NO. P094
soft tissue quality compromise outcomes. Reference points for How Can a More Stable Cemented Femoral Stem
traditional component positioning are lost. We report the results
of our initial 30 cases of Revision Hip Surgery where imageless Be More Problematic Than a Less Stable Stem?
computer navigation was used validate acetabular component Edward Ebramzadeh, PhD, Los Angeles, CA (a – Zimmer)
position. Materials And MethodsWe used an Imageless system for Sophia Sangiorgio, MSc, Los Angeles, CA (a – Zimmer)
acetabular reconstruction with a tracking device positioned in the Donald B Longjohn, MD, Torrance, CA (e – Zimmer)
pelvic. During acetabular component placement and when William McGarry, MSc (n)
cementing in liners (standard or constrained) we identify the Keiichiro Ichiryu, BSc (n)
cups orientation and position quantitatively and qualitatively. Fabrizio Billi, PhD, Los Angeles, CA (n)
The acetabular component is placed with greater accuracy in rela-
Lawrence D Dorr, MD, Inglewood, CA (e – Zimmer)
tion to the pelvis through this method. Results30 cases of
Acetabular Revision Hip surgery are reported. Our target number Abstract: Although rougher surface finishes increase femoral
we were aiming at was 45±5° for Inclination and 25±5° for stem stability within the cement mantle, many clinical studies
Anteversion. The mean computer navigation values for have speculated that rougher surfaces produce more debris than
Inclination were 45.8 ± 6.1°(37-57°) and for anteversion was less stable polished stems. Unfortunately, this has not been
22.5 ± 7.4° (11-34°). We validated acetabular position postoper- quantified to date. This study assessed which femoral design
atively through Xrays and found the mean radiographic parameters maximize stability and minimize interfacial wear
Inclination to be 45.9±3.7° (39-54°) and anteversion 22.5± 6.9° debris. Three dimensional cyclic motion was measured at the
(6-32°). DiscussionWith better component position long term stem-cement interfaces of eight stem-types differing in taper,
survival may improve due to correct wear, reduced impingement surface finish, and proximal geometry. These tangential motions
and dislocation rates. We report this novel surgical technique were then used in a fretting wear study, which evaluated the
which may reduce component malpositioning during revision characteristics of surgical cement against metal disks of the same
surgery and serve as a tool for better results. three surface finishes. Tangential motions from the stability
study and wear characteristics from the fretting simulation were
combined to assess an indirect quantification of the total debris.
While these results cannot quantify the total volume lost for
each stem, they provide a means of comparison relative to each
stem-type. For straight stems, surface finish had the greatest rela-

412 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 413

tive effect on wear. Rough straight stems generated at least twice POSTER NO. P096
as much metal and cement debris as polished stems, regardless Surgical Approach, Anesthesia Techniques, and
of proximal stem geometry. In contrast, for double-tapered
stems, proximal stem geometry was the most important variable, Rehabilitation Protocols Effect Recovery Following
and non-flanged stems generated approximately four times as THA
much debris as flanged stems. Although grit-blasted surface Richard A Berger, MD, Chicago, IL (a, e – Zimmer)
finishes decrease motion of straight stems, the amount of Sheila Sanders, RN, Hickory Hills, IL (n)
motion is still sufficient to produce more debris than identical,
Kate A Buccheit, MPT (n)
looser, polished stems. However, the difference between a
polished and a matte double-tapered stem is inconsequential Elizabeth S Thill, BSN, Algonquin, IL (n)
compared to the effect of proximal stem geometry. Marcus Wimmer, PhD, Chicago, IL (n)
Madelaine Hildebrand, MD, Halle/Saale, Germany (n)
POSTER NO. P095 Kirsten Moisio, PT, PhD, Chicago, IL (n)
Charnley’s LFA for Paget’s Disease of the Hip: Asokumar Buvanendran, MD (n)
A Concise Follow Up of 15-28 Years of a Abstract: ‘Minimally invasive’ hip replacement has promised
rapid recovery. However, some ‘minimally invasive’ techniques
Previous Report may inadvertently stretch or tear the underlying soft tissue. In
Shreyash Mahendra Gajjar, MD, Liverpool, addition, the effect of improved anesthesia and rehabilitation
United Kingdom (n) protocols may also increase recovery. Twenty-eight patients were
Martyn Porter, MD, Wigan Lancashire, United Kingdom (n) enrolled in an IRB approved prospective randomized study
Abstract: The current report presents a further follow-up of our comparing two approaches to THA. One technique (Group A)
previously reported our results of 98 Charnley Low-Friction involved stretching the abductors in a non-anatomic position
Arthroplasty in 76 patients with Paget’s disease of the hip at 15 to during a minimally invasive approach. The second technique
30 years postoperatively A total of 98 Charnley low-friction (Group B) did not stretch the abductors during surgery. Patients
arthroplasties were performed on 76 patients. There were 27 men were given identical preop teaching with expectations of rapid
(37 hips) and 49 women (61 hips) with an average age of 67.4 recovery and short hospital stay. The anaesthesia and postopera-
years (range, 51-79 years). All operations were performed by the tive analgesia was identical. Patient received identical cementless
trans-trochanteric or antero-lateral approach. Patients were regu- total hip components. Surgical time, complications, length of
larly follow-up in the post-operative period for clinical and radi- stay, narcotic use, and recovery parameters were collected. There
ological evaluation. When component revision was used as the was no statical differences in age, gender, or BMI in the two
endpoint, the survivorship of the acetabular component was groups. Using this improved anesthesia and rehabilitation
93% at 15 years (CI, 81% to 98%), 83% at 20 years (CI, 59% to protocol, 57% of the patents in Group A and all the patients in
93%), 72% at 25 years (CI, 41% to 89%) and 36% at 30 years group B were discharged to home the day of surgery. The tech-
(CI, 2% to 78%). The survival of the femoral component was nique the stretched the abductor was statically quicker, but also
91% at 15 years (CI, 80% to 96%), 84% at 20 years (CI, 60% to had statically higher narcotic use, statically longer hospital stay,

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

94%), 84% at 25 years (CI, 60% to 94%) and 72% at 30 years statically longer time to ambulate independently, and more
(CI, 38% to 89%). The survival of both components was 89% at complications (one trochanteric fx). A comprehensive approach
15 years (CI, 76% to 95%), 81% at 20 years (CI, 56% to 92%), to THA including improved anesthesia and rehabilitation proto-
81% at 25 years (CI, 56% to 92%) and 81% at 30 years (CI, 56% cols allowed most patient to leave the hospital the day of surgery
to 92%). When component failure was used as the endpoint, the regardless of surgical approach. The patients with the approach
survivorship of the acetabular component was 78% at 15 years that stretched the underlying soft tissue, used more narcotic
(CI, 64% to 87%), 66% at 20 years (CI, 48% to 80%), 43% at 25 postoperatively, stayed in the hospital longer, had longer time to
years (CI, 21% to 62%) and 12% at 30 years (CI, 2% to 32%). ambulate independently, and more complications.
The survival of the femoral component was 76% at 15 years (CI,
62% to 85%), 67% at 20 years (CI, 48% to 80%), 47% at 25 years POSTER NO. P097
(CI, 25% to 67%) and 7% at 30 years (CI, 1% to 26%). The Ceramic Liner Malseating in Total Hip Arthroplasty
survival of both components was 74% at 15 years (CI, 59% to Douglas E Padgett, MD, New York, NY (n)
83%), 64% at 20 years (CI, 44% to 78%), 43% at 25 years (CI, Anna Miller, MD (n)
20% to 64%) and 7% at 30 years (CI, 1% to 27%). Long term Edwin P Su, MD, New York, NY (n)
results of Charnley’s Low Friction Arthroplasty achieved in this
Mathias P G Bostrom, MD, New York, NY (n)
patient group are comparable to general arthroplasty population.
Bryan J. Nestor, MD, New York, NY (n)
Abstract: Alternative bearings like ceramics have become increas-
ingly popular due to improved wear properties and are the
bearing of choice for younger patients at our institution.
Unfortunately, we have observed instances of incomplete seating
of the ceramic insert into the acetabular shell. The purpose of
our study was to report the incidence of this occurrence in a
consecutive series of ceramic bearing total hips Between May
2003, and Dec 2005, 205 hips in 177 patients were implanted
with the cementless titanium alloy Trident PSLTM acetabular
shell and the SecurefitTM stem (Stryker Corp, Allendale, NJ)
with alumina ceramic bearings. The ceramic liner with its tita-
nium jacket is placed into the shell lining up the appropriate
markings and then impacted. Radiographs were reviewed for

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
413
PPSE 07:Layout 1 1/12/07 1:40 PM Page 414

shell-liner divergence indicating incomplete seating of the insert were available for all hips. Grading of HO was done according to
Radiographic analysis demonstrated incomplete seating of the the Brooker classification, at a mean follow up of 19 months
liner into the acetabular shell in 24 cases for an incidence of 11.7 following surgery (range=12- 27 months). The distribution of
%. Incomplete seating was always noted in the most caudad HO was: Grade I=10 hips (8%); Grade II=9 hips (7%); Grade
aspect of cup at the level of the teardrop. To date, there have been III=4 hips (3%); and Grade (IV)=2 hips (1%). The overall inci-
no instances of late liner dissociation Incomplete seating of the dence of HO following 2INC-THA was 19%. No patient required
liner into the shell aceramic bearing is a concern for 2 reasons: repeat surgery for HO. The one patient with Grade IV HO had hip
liner dissociation and the possibility of metal fretting due to stiffness, but did not elect additional surgery. The location of HO
micromotion. While often subtle, we were surprised by the lesions in this study was anterior, along the planes of the gluteus
seemingly large incidence of this occurrence. While material medius and minimus muscles. The incidence of HO following
failure has not been a problem to date, we continue to monitor 2INC-THA in this series was 19%, a figure that is within the range
this patients closely for any adverse outcome related to this of reported incidences of HO associated with other, standard
phenomena. surgical approaches for primary THA. While clinically significant
HO requiring repeat surgery did not develop in any patient, these
POSTER NO. P098 data suggest that HO is a risk with 2INC-THA. Therefore, patients
Use of a Constrained Acetabular Component for at risk for HO formation should be considered for prophylactic
treatment despite the less invasive nature of 2INC-THA.
Recurrent Dislocation of the Hip
Sarah Shubert Banerjee, MD, El Paso, TX (n) POSTER NO. P100
James V Bono, MD, Boston, MA (e – Stryker Howmedica) Simultaneous vs. Staged Cementless Bilateral Total
Abstract: The constrained acetabular component has been FDA
approved since 1987, but historically has had problems with
Hip Arthroplasty: Perioperative Risk Comparison
catastrophic mechanical failure and early loosening. Advances in Keith R Berend, MD, New Albany, OH
design and better patient selection have improved results with (a, d, e – Biomet, Inc)
this prosthesis. We present intermediate follow-up of twenty Adolph V Lombardi Jr, MD, New Albany, OH
patients treated by a single revision joint surgeon, with only one (a, d, e – Biomet, Inc.)
failure. Between 1996 and 2005, twenty patients referred for Joanne B Adams, New Albany, OH (a – Biomet, Inc.)
recurrent instability of the hip were treated with a constrained Abstract: For patients presenting with bilateral hip disease, the
component. Patients were required to have failed conservative decision to perform arthroplasties simultaneously under a single
treatment, and have a minimum of 3 dislocations. A constrained anesthetic or staged remains controversial. The purpose of this
liner was used only if there was no bony or soft tissue impinge- study is compare the results of simultaneous versus staged bilat-
ment at surgery, and the existing components were well-posi- eral cementless THA using a single femoral stem design, and the
tioned. Post-operatively, patients were full weight bearing. The lateral decubitus position, with special emphasis on periopera-
overall success rate was 95 percent, with one failure in a young tive complications and reimbursement to the surgeon and
patient. All patients but two were elderly. The majority of patients hospital. Bilateral THA in 277 patients were reviewed: performed
had problems of soft tissue laxity or neuromuscular disease,
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

simultaneously in 167 patients and staged in 110 at an average

including lower extremity neuropathy and dementia. There was 8.1 months apart. Preoperative clinical scores were similar
no radiographic evidence of loosening or osteolysis in any between groups; however, staged patients were significantly
patient at final follow up (average 43 months, range 4-103 older (57 vs. 52-years-old; p<0.0001), and more likely to be
months). When used judiciously, the constrained liner can yield Charnley class C (38% vs. 14%; p=0.0000) and female (57% vs.
excellent results. The procedure involves less blood loss and intra- 40%; p=0.0051). Cumulative single day blood loss and blood
operative time in an elderly population, and allows immediate units transfused were significantly higher in simultaneous
full weight bearing. This component should not be used patients (p<0.0004) while cumulative length of stay was lower
frequently— in the period of our study, it was used in less than (3.9 vs. 5.6 days; p<0.0001). Inpatient adverse events were more
10 percent of hip revisions. There is a greater risk of failure in common in the simultaneous group (71.3% vs. 42.3%;
young patients, and other options should be explored in this p=0.0000). Fewer simultaneous patients met physical therapy
group. goals by discharge (53.3% vs. 79.5%; p=0.0000), more required
discharge to a rehabilitation facility (40.7% vs. 18.6%;
POSTER NO. P099 p=0.0000), and more required subsequent hip surgery (3.9% vs.
Incidence of Heterotopic Ossification Following 0.5%; p=0.0116). A 28% cummulative loss in hospital reim-
Primary Two-Incision Total Hip Arthroplasty bursement and 15% overall loss in surgeon reimbursement was
seen. While accomplishing bilateral THA under a single anes-
B Sonny Bal, MD, Columbia, MO (n)
thetic provides shorter cumulative length of stay, closer exami-
Jason Lowe, MD, Columbia, MO (n) nation of perioperative risks demonstrates that staged
David Daniel Greenberg, MD, Columbia, MO (n) procedures done in the lateral decubitus position may be safer
Thomas Joseph Aleto, Jr, MD, Columbia, MO (n) for the patient. Based upon issues of increased perioperative
Abstract: Primary total hip arthroplasty with the MIS two-incision complications, increased risk of reoperation, and decreased
approach (2INC-THA) is reportedly less traumatic to muscles. reimbursement to the hospital and surgeon, the authors can no
Some reports suggest earlier recovery and return of function longer safely offer simultaneous THA to our patients.
following 2INC-THA. Accordingly, the incidence of heterotopic
ossification (HO) should be less following 2INC-THA than with
other surgical approaches; this hypothesis was investigated in the
present study. Radiographs of a consecutive single-surgeon series
of 129 2INC-THAs were examined by an independent investi-
gator. Standard AP, frog lateral, and shoot-through lateral views

414 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 415

POSTER NO. P101 object can hardly be placed as accurately as required to distin-
Component Position of Two Incision Minimally guish implant sizes. A fixed magnification is more accurate and
reliable. Alternatively, we recommend, if present, calibration on
Invasive vs. Standard Total Hip Arthroplasty a contralateral implant of known dimensions.
Susan Lai Williams, MD, Bowie, MD (n)
Paul A Manner, MD, Seattle, WA (e – Zimmer) POSTER NO. P103
Casey Bachison, MD, Detroit, MI (n) Total Hip Resurfacing for Legg-Calve-Perthes
Abstract: Minimally invasive surgery (MIS) for total hip arthro- Disease
plasty (THA)has sparked much interest as well as controversy in
Harold S Boyd, MD, Salem, OR
the orthopaedic community. There are limited reports of results
comparing MIS to standard approaches given the recent nature (a – FDA Phase II Conserve Plus (WMT), b – WMT,
of the development of the technique. This study focuses on e – Wright Medical, Stryker)
component position as assessed by post operative radiographs Michael A Mont, MD, Baltimore, MD
which is the most important factor contributing to hip stability. (a – FDA Phase II Conserve Plus (WMT), b – WMT,
In the year 2004, 109 consecutive THA were performed by a e – Wright Medical, Stryker)
single surgeon who is proficient in both two incision MIS THA German A Marulanda, MD, Baltimore, MD
and standard direct lateral THA. Seventy-six two incision MIS (a – FDA Phase II Conserve Plus (WMT), b – WMT,
THA and 33 standard THA were performed. Post operative radi- e – Wright Medical, Stryker)
ographs were assessed for acetabular inclination, acetabular
Abstract: Metal on metal total joint resurfacing has been offered
anteversion, and femoral stem angulation. The average age of
as an alternative to conventional total hip arthroplasty. Several
patients in the two incision MIS THA groups was 58.28 as
reports have shown the benefits of this procedure in young, high
compared to 63.21 in the standard THA group. The mean BMI
activity patients, and in the setting of extra-articular deformities
was 26.2 and 28.9 for two incision MIS THA and standard THA
and pre-operative hardware. Legg-Calve-Perthes disease (LCP) is
respectively. Comparison of acetabular inclination between
a condition of bone that affects young patients (4 to 8 years of
groups was 42.2 degrees for two incision MIS and 38.7 for stan-
age) and it is characterized by the premature collapse of the
dard THA which is statistically significant but not clinically
femoral head due to interruption in the blood supply. Patients
significant. Acetabular anteversion was 16.5 and 15.5 for the two
with this condition may require total hip arthroplasties at
incision MIS and standard groups respectively. Placement of
younger ages due to an earlier onset of osteoarthritis and alter-
femoral stem was within 5 degrees varus/valgus for both groups.
ations in the femoral head morphology. Conventional hip
Radiographic assessment of component position of THA in two
arthroplasty is technically difficult in this subgroup of patients
incision MIS versus standard direct lateral approach reveals no
and has not shown favorable results in gait and biomechanical
significant difference. Components are placed reliably and
analysis. The purpose of this study was to report a multi-center
reproducibly with both techniques.
technique and the results of metal on metal total hip resurfacing
POSTER NO. P102 for the treatment of LCP disease.From June 2001 to April 2005,
nineteen metal on metal resurfacings were performed in

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

Avoiding the Accuracy and Reliability Traps of eighteen patients with underlying diagnosis of LCP. Ten men
Digital Templating in Joint Arthroplasty and 8 women were prospectively enrolled in this multi-center
Bernd P Grimm, PhD, Aachen, AA Germany IRB approved study. An antero-lateral approach to the hip was
(a – Stryker, Biomet) used in 4 cases and a posterior approach with a trochanteric slide
was used in 15 cases. The trochanteric cut was performed distal
Casper Schoenhuth, MD (n)
to the femoral neck. Fixation was achieved with two cables (one
Ide Christiaan Heyligers, MD, Heerlen, Netherlands distal cable through the trochanter for fixation and an additional
(a – Stryker, Biomet) on top for compression). In all procedures, special attention was
Martijn Franken, MEng (n) given to remove any excess tissue that could produce impinge-
Abstract: Templating is an important for preoperative planning ment. The patients were followed-up for a mean of fifty-one
in joint arthroplasty as it improves clinical outcome. Clinical months (range, 26 to 72 months). Clinical assessment was
studies have reported less accurate implant sizing using digital performed with preoperative and postoperative Harris hip scores
templating instead of the standard manual technique but could (HHS). Favorable outcome was defined as a HHS greater than
not identify the source of this problem. This study investigates 80 points and no further revision surgery. Radiographic analysis
why templating accuracy and reliability is lower using digital included in all cases measurements of cup inclination, stem-
systems. Postoperative AP radiographs from a consecutive cohort shaft and neck-shaft angles, and the presence or absence of radi-
of 52 THA patients (Stryker ABG-II) were retrospectively olucencies or cup migration. Ninety five percent of the
templated for stem and cup size using Endomap V2.01 software. procedures (18 of 19 hips) had a favorable result at latest follow-
Two independent observers were blinded to the actual implant up. The mean preoperative HHS for all patients was 48 points
size to which their measurements were compared and catego- (range, 30 to 67) compared to a mean postoperative HHS of 92
rized as correct or over- or undersized. The x-rays were calibrated points (range, 52 to 98 points). The only case of unfavorable
either by using a 30mm ball or by setting a fixed magnification outcome (HHS of 52 points) occurred early on the learning
(115%). Using the calibration ball, templating accuracy was low curve for the procedure in a patient with bilateral collapse of the
for both observers with only 27% (29%) of the stems and 23% femoral head. The patient is doing well with a HHS greater than
(15%) of the cups sized correctly. 21% (25%) of the stems and 90 points after conversion to a standard hip arthroplasty. The
39% (43%) of the cups were wrongly estimated by two or more mean postoperative neck-shaft angle was 144 degrees (range,
sizes. This percentage dropped significantly to 6% (p=0.02, 130 to 155 degrees) in the anterior-posterior projection (AP)
Fisher exact test) for the stems and to 19% for the cups (p=0.03) and 23 degrees (range, 7 to 35 degrees) in the lateral films. The
using the fixed magnification. In clinical practice digital stem-shaft angle was similar with a mean of 147 degrees (range,
templating accuracy can be critically low because the calibration 132 to 164 degrees) in the AP and 22 degrees (range, 5 to 34

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
415
PPSE 07:Layout 1 1/12/07 1:40 PM Page 416

degrees) in the lateral. The mean cup inclination was 45 degrees be at highest risk. Even with refined and improved surgical tech-
(range, 32 to 53 degrees). There were no radiolucencies and no niques and the use of state of the art metal alloys and compo-
migration of the cup in the study. The short term results for nents, femoral stem fractures remain as a consistent
metal on metal hip resurfacing for the treatment of LCP were complication of standard total hip arthroplasties.
excellent and compare favorably to those found in the literature.
The trochanteric advancement described in this study provided POSTER NO. P105
additional support to the deformed anatomy of the hip joint. Cephalization of the Center of Rotation in Total Hip
The investigators believe that this is a valid indication for total
hip resurfacing. The ongoing study of metal on metal total hip
Replacement: A Role for Preoperative Templating
resurfacing will eventually describe the long term results, safety, Christopher Michael Farrell, MD, Fair Haven, NJ (n)
and complications of this procedure. Alejandro M Gonzalez Della Valle, MD, New York, NY (n)
Stephen Lyman, PhD, New York, NY (n)
POSTER NO. P104 Kristin L Foote, New York, NY (n)
Hip Surgery Complications: Multicenter Study of Bryan J. Nestor, MD, New York, NY (n)
Femoral Stem Fractures after Total Hip Arthroplasty Abstract: The ability to equalize leg length in total hip replace-
ment depends on accurate prediction of cup position and thus
Michael A Mont, MD, Baltimore, MD (a, e – Stryker)
hip center of rotation (COR); and adjusting femoral neck length
Oliver A Perez, MD, Baltimore, MD (e – Stryker)
accordingly. We hypothesized that implantation of an unce-
Joseph T Moskal, MD, Roanoke, VA (e – Stryker) mented cup results in cephalization of the hip COR when
William J Hozack, MD, Philadelphia, PA (e – Stryker) compared to the normal hip. Therefore, the femoral lesser
Marvin E Steinberg, MD, Philadelphia, PA (e – Stryker) trochanter to center (LTC) distance must be lengthened accord-
James B Stiehl, MD, Milwaukee, WI (e – Stryker) ingly to insure proper leg length. The preoperative and 6-week
David S Hungerford, MD, Baltimore, MD (a, e – Stryker) postoperative AP radiographs of 84 consecutive total hip replace-
German A Marulanda, MD, Baltimore, MD (n) ments performed by a single surgeon in patients with a normal
Thorsten M Seyler, MD, Baltimore, MD (n) contralateral hip were reviewed. All preoperative x-rays had been
prospectively templated. All radiographs were obtained using a
Abstract: The incidence of femoral stem fracture has decreased in
standardized technique and variation in magnification adjusted
the past forty-four years with advances in the fields of metallurgy
for by using the known femoral head diameter. Cephalization of
and total joint replacement surgery. Recent studies show femoral
the COR occurred in 48 hips (57.1%), mean 2.8 ±2.1mm (range:
stem fractures in 0.23% to 19% of patients with a conventional
0.2-7.8mm). Cephalization of the COR was accurately predicted
hip arthroplasty. Several risk factors (stem design, amount and
by preoperative templating in 42 hips (87.5%). However, a
quality of fixation, amount of support at the level of the calcar,
concomitant lengthening of the LTC was only achieved in 54.8%
activity level, presence of granuloma, and many others) have
of the hips. None the less, the overall mean leg length discrepancy
been associated with this occurrence. This study characterized
was 1.1 ±3.9mm. The leg length discrepancy was less than 7 mm
the demographic and radiographic aspects of patients who
in 79 of 84 hips (94%). Among the remaining five hips, only two
underwent revision of a femoral stem fracture. Thirty patients
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

(2.4%) had a LLD greater than 8 mm,(12.2 mm shorter, and 10.8

(30 hips) with a femoral stem fracture who underwent revision
mm longer). The primary source of error in templating for leg
hip arthroplasty at six institutions were included in this study. A
length was the femoral neck cut (p<0.001). Proper templating
characterization of various demographic and clinical factors
can minimize postoperative leg length discrepancy. Interestingly,
such as gender, weight, activity level, stem characteristics (design,
the greatest source of error was in the femoral neck cut suggesting
size, and orientation) and quality of cement mantle was
that calculating leg lengthening on the basis of the neck cut alone
performed. In addition, a pre-operative evaluation of stem inter-
is unreliable.
faces on anterior-posterior and lateral radiographs was made.
There were 17 men and 13 women identified with fourteen
POSTER NO. P106
different types of prosthetic implants. The mean age at the time
of stem fracture was 57 years (range, 36 to 89 years). The mean Comparison of Minimally Invasive Two-Incision
weight of the patients in our series was 90 kilograms (range, 75 Total Hip Approach with the Direct Lateral Approach
to 110 kilograms) at the time of stem fracture, and the average Matthew J Levine, MD, Durham, NC (n)
time to stem fracture was 146 months (range, 46 to 288
Kris West, Med Student, Arlington, VA (n)
months). The mean height of the patients was 173 cm (range,
155 to 188 cm). Factors that appeared to be strongly associated
James D Michelson, MD, Columbia, MD (n)
with femoral stem fracture included cement fixation (all but Paul A Manner, MD, Seattle, WA (e – Zimmer)
three hips), young age, high activity levels prior to fracture, and Abstract: There has been much debate recently regarding bene-
obesity (mean Body Mass Index of 31.1). Six of the fractured fits of minimally invasive total hip replacement. There are no
femoral stems were made with “super alloys” such as forged high long term prospective studies comparing a two incision
strength cobalt-chromium-molybdenum and titanium. approach to a standard direct lateral THA. We retrospectively
Radiographic evaluation revealed progressive radiolucencies reviewed the senior author’s high volume total hip experience
and/or other component problems (malalignment, undersizing, over a three year period (2002-2004) during which he adopted
not full stem seating) in the majority of hips. One patient with the two incision approach. In this series 126 cases were MIS
a cemented T-28 prosthesis had proximal-lateral lucency for ten while 75 were standard THA. There was a significant difference
years before the femoral stem fracture. One patient presented a in length of stay (days) with the MIS at 2.20 (2.03-2.37) when
femoral stem fracture in the setting of infection. A total of fifteen compared to standard THA 3.73 (3.37-4.09) (p<0.01). The
different characteristics associated with femoral stem fractures shorter operative time (minutes) in the MIS group was also
were discussed. This study has identified various risk factors for significant 98.01 (93.42-102.59) versus 110.12 (102.08-118.15)
hip arthroplasty stem fractures. Patients with continued high (p<0.01). There were no significant differences in overall compli-
activity levels despite impending radiographic failure appear to cation rate or rate of re-operation through a 12 month follow-up

416 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:40 PM Page 417

period. When divided into sequential groups of 42, there is a POSTER NO. P108
significant decrease from the first to the last cohort in length of Total Hip Arthroplasty in Patients Younger Than 25
stay (2.76 days vs. 1.89 days) (p<0.01), operative time (111.26
minutes vs. 83.19 minutes) (p<0.01), and estimated blood loss Years of Age
(575.61cc vs 441.67cc)(p=0.02). Our series suggests that a high John C Clohisy, MD, Saint Louis, MO (a, e – Zimmer)
volume total hip surgeon can safely transition from a direct Thorsten M Seyler, MD, Baltimore, MD (n)
lateral THA to a two incision MIS approach with a decrease in Frank R. Kolisek, MD, Indianapolis, IN (e – Stryker)
length of stay and operative time, and with further experience Ronald Emilio Delanois, MD, Lutherville, MD (*)
those values will continue to decrease. Johannes F Plate, BS, Heidelberg, Germany (n)
POSTER NO. P107 Michael A Mont, MD, Baltimore, MD (e – Stryker)
Abstract: Since the introduction of total hip arthroplasty (THA)
Multicenter Analysis of Total Hip Arthroplasties: in the 1960’s by Sir Charnley, this procedure has been a successful
What Are the Reasons For Revision? treatment modality for elderly patients with advanced arthritic
Derek M Bennett (n) disorders predictably providing pain relief and restoration of
German A Marulanda, MD, Baltimore, MD (n) function. In contrast, there have been only a few reports on THA
Khaled J Saleh, MD, Charlottesville, VA in young patients. Most of these studies are small case series
reporting the results of certain subpopulations of young patients
(e – Stryker Orthopaedics, Smith & Nephew)
with sickle cell disease, systemic lupus erythematosus, and juve-
Issada Thontrangan, MD (n) nile rheumatoid arthritis. The outcome of THA in these subpop-
Mike Kuskowski, PhD, Minneapolis, MN (n) ulations has been associated with a high complication rate and
Edward Y Cheng, MD, Minneapolis, MN (n) questionable implant survival. Recently, with advances in pros-
Peter F Sharkey, MD, Philadelphia, PA thetic designs and improved surgical techniques reports have
(c – Stryker Orthopaedics) shown improved results in these difficult to treat patients. The
James B Stiehl, MD, Milwaukee, WI (c – Zimmer) purpose of the present study was to assess the clinical and radi-
Michael A Mont, MD, Baltimore, MD ographic outcome of THA in patients younger than 25 years of
(c – Stryker Orthopaedics, Wright Medical Technology) age. This multicenter study with five investigators evaluated 70
hips in 58 patients. Of the 58 patients, 37 were female and 33
Abstract: Primary total hip replacements have reported success
were male. The mean age at the time of arthroplasty was 19.6
rates greater than 95% in many series at follow up of greater than
years (range, 12 to 25 years), with a mean BMI of 26.8 (range,
ten years. However, factors such as increased activity levels, a
16.7 to 47.4). The most common causes of arthritis included
younger patient population, and increased life expectancy, have
avascular necrosis of the hip in 26, osteoarthritis 19, sickle cell
made the revision of a hip replacement a more prevalent proce-
disease in 11, inflammatory arthritis in 9, congenital dysplasia of
dure. This multicenter study evaluated the most common indi-
the hip in 6, Legg-Calve-Perthes disease in 6, posttraumatic
cations for revision hip arthroplasty and related these findings to
arthritis in 4, and slipped capital femoral epiphysis and Morquito
several variables (such as demographic characteristics and time
syndrome in one patient each. An attempt was made to correlate
after primary hip arthroplasty). A multicenter review of all revi-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

the clinical failures with underlying pathologies that have been
sion hip arthroplasties over a six year time period was performed
implicated in negatively influencing the implant survival rate.
identifying 225 patients who underwent 237 hip revisions. The
Patients were evaluated using the Harris Hip rating system and
indication for revision surgery and the failure mechanism were
radiographic analysis. At a mean follow-up of 72 months (range,
determined by recording the pre-operative clinical and radi-
24 to 204 months) implant survival was 94%, with one death not
ographic information along with a review of the intra-operative
related to surgery. The Harris Hip scores increased from a mean
findings. Causes of failure and various demographic factors were
of 41 points (range, 5 to 85 points) to a mean of 83 points (range,
analyzed in relation to time to failure The mean time to revision
39 to 100 points) at final follow-up. The outcome was excellent
was 83 months. The identified cause of failure was aseptic loos-
to good for 65% (44 hips), fair for 19% (13 hips), and poor for
ening in 123 hips (51.9%), instability in 40 hips (16.9 %), and
16% (11 hips). Four patients required revision surgery with two
infection in 37 hips (5.5%). When categorized by diagnosis, the
being done for deep joint infection, one for recurrent disloca-
mean time to failure in patients with osteonecrosis, dysplasia,
tions, and one for aseptic loosening. Sickle cell disease and calcar
post-traumatic arthritis, and primary osteoarthritis was 64, 83,
fracture were the associated pathologies in the two infection
73, and 82 months respectively. When stratified into two groups
cases. Other common complications included dislocations and
(less than 5 years, greater than 5 years) 118 of 237 (50%) revi-
wound healing problems. There are only a few reports focusing
sions occurred in less than 5 years with 33%) due to instability
on the results of total hip arthroplasty in this age group with
and 24% as a result of infection. A complete analysis with all the
many of them reporting specifically on the outcome of one
variables included in the study will be presented along with
subpopulation. It has been suggested that THA should generally
evidence-based options to reduce the incidence of revision hip
be avoided in young patients, especially when alternative treat-
arthroplasty. This study showed that the major causes of early
ment methods are available. Based on the presented findings, the
failure were instability and deep infection. Thus emphasizing the
authors of the present study conclude that THA is a viable option
significance of appropriate component positioning and imple-
for patients 25 years of age or younger, but one must realize that
mentation of meticulous intra and postoperative protocols to
any reconstructive procedure in this young population will have
minimize complications.
to be revised at least once during a patient’s lifetime. The authors
await long-term data to see if these encouraging results hold true.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
417
PPSE 07:Layout 1 1/12/07 1:41 PM Page 418

POSTER NO. P109 active straight leg raise prior to release; following surgery patients
Safety of Vioxx in the Postoperative Period were able to perform this activity without pain. There was no
significant statistical difference in the femoral offset between this
Following Total Knee Arthroplasty group of patients and the matched control group. This relatively
James J Purtill, MD, Philadelphia, PA (n) uncommon condition should be considered in the differential
Eric Smith, MD, Merion Station, PA (n) diagnosis of all patients who present with groin pain following
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) THA. Various factors such as larger uncemented acetabular cups,
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker) impingement of tendon against femoral neck, anatomical varia-
William J Hozack, MD, Philadelphia, PA (e – Stryker) tion of the head-neck junction, alteration of the course of the
iliopsoas tendon, or increase in femoral offset might be related
Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
to the development of this disabling condition. Surgical release
Abstract: Vioxx (Rofecoxib) was prescribed widely for patients gives excellent results in these patients.
undergoing joint arthroplasty in an effort to reduce narcotic usage
in the postoperative period in the early 2000s. Though effective, POSTER NO. ORS 1
issues regarding its potential cardiovascular toxicity lead to the
voluntary withdrawal of this drug from the market on September
The Stability of Straight Cemented Femoral Stems
30, 2004. This study analyses the cardiovascular morbidities and as a Function of Surface Finish, Proximal Stem
mortality rates in total knee arthroplasty (TKA) patients who Geometry, and Interface Bonding Conditions
recieved Vioxx in the postoperative period. We retrospectively
Sophia N Sangiorgio, Los Angeles, CA
reviewed the clinical records of 1,963 consecutive patients who
underwent 2,395 TKA between October 1, 2002 to September 30, (a – Zimmer, Implant)
2004. As an adjunct to epidural anesthesia and narcotic pain Edward Ebramzadeh, Los Angeles, CA
medications in the postoperative period, a daily dose of Vioxx (a – Zimmer, Implant)
50mg was routinely prescribed to all TKA patients for 5 days or Donald B Longjohn, Los Angeles, CA (a – Zimmer, Implant)
until discharge, whichever was shorter. We compared the inci- Lawrence D Dorr, Inglewood, CA (a – Zimmer, Implant)
dence of in-hospital postoperative cardiovascular morbidity and
perioperative mortality of patients receiving Vioxx with 2,319
control patients during a later period who did not receive any
COX-II inhibitors. There was no significant difference in the
SCIENTIFIC EXHIBITS
demographic make up or morbidity profile (as measured by ASA)
between the two groups. There was no statistically significant
SCIENTIFIC EXHIBIT NO. SE01
difference in the overall incidences of in-hospital MI, arrhythmia,
CVA and mortality in patients receiving Vioxx ( 0.46%, 0.08%, Types of THA Head Damage Due to Dislocation and
0.15%, and 0.31% respectively) and the control patients who did Reduction - Causes and Effects
not receive COX-II inhibitors( 0.46%, 0.30%, 0.46%, and 0.61% William L Jaffe, MD, New York, NY
respectively). It appears that using Vioxx as an adjunct to narcotics
(a, b, e, – Stryker Orthopaedics)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

in the postoperative period after TKA did not confer additional

cardiovascular risks to the patient. Short-term use of non-opiate
Eric Strauss, MD, New York, NY (n)
analgesics provides immense benefits for pain control to patients Fredrick J Kummer, PhD, New York, NY (a – Stryker
undergoing TKA without conferring additional risks. Orthopaedics, Mitek Corp., Biomet, Zimmer, Synthes)
Recent case reports have shown various types of THA head
POSTER NO. P110 damage attributed to dislocation and reduction. To understand
Illiopsoas Tendonitis: A Complication after Total Hip these findings and our own observations of retrieved head
damage, we developed a laboratory method to simulate a dislo-
Arthroplasty cation and difficult reduction of a THA in a controlled, repro-
William Lindsay Walter, MD, Waverton, Australia (n) ducible manner. Five types of heads (metallic and ceramic) and
Michael O’Sullivan, FRACS (n) two types of metallic shells were used to produce various degrees
Chen Chin Tai, FRCS, London, United Kingdom (n) of head damage by varying loads and number of cycles. The type,
William Keith Walter, MB, Waverton, Australia (n) nature, extent and profiles of damage were quantified by SEM,
Abstract: Tendinopathy is an uncommon cause of pain EDAX, and Talysurf and interferometric profilometry. These
following total hip arthroplasty (THA); Iliopsoas tendonitis has damaged heads were tested in a hip simulator to compare with
been reported in a small number of papers in the literature. We undamaged controls using two types of polyethylene inserts to
present a series of fifteen patients with iliopsoas tendonitis quantify wear by the amount of polyethylene debris generated.
following THA. Between 1992 and 2004, 15 patients (16 cases) Oxinium heads showed disruption of the ceramic coating, the
presenting with severe anterior groin pain were diagnosed to other heads showed metallic transfer films from the shells in
suffer from iliopsoas tendonitis. The mean presentation time thicknesses of 50 to 150 microns with metal heads having a
was 20.3 months. Surgery was carried out after failure of conser- greater amount than ceramic. Shell design was also a factor in
vative measures. All patients underwent divison of the iliopsoas the amount of damage as metallurgical analysis showed the two
tendon combined with bevelling of the anterior cortex of the shells were identical. Wear test results from the hip simulator
femoral neck. One patient required re-position of acetabular demonstrated that transfer films were deleterious, with wear
prosthesis. The mean follow up period from iliopsoas tendon severity correlated to film height. These results suggest that any
release was 36.4 months. The mean Harris Hip score improved surgery for a dislocated THA should include replacing the head,
from 58 to 91 following iliopsoas surgery. Postoperative goin and that those patients who are nonoperatively reduced be
pain was resolved completely in 68.8% cases and reported as closely monitored for the potential effects of head damage on
mild in the remaining cases. All patients were unable to perform polyethylene wear.

418 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 419

SCIENTIFIC EXHIBIT NO. SE02 been conducted focusing on radiographic assessment, wear, and
Improved Analyses in the Swedish Total Hip outcome measures; Retrieval studies of highly cross-linked poly-
ethylene components have been performed. Submicron wear
Arthroplasty Register particles of polyethylene are the primary cause of periprosthetic
Johan Nils Karrholm, MD, Goteborg, Sweden (n) osteolysis. The submicron particles result from the continued
Goran Garellick, MD, PHD, Goteborg, Sweden (n) drawing and re-drawing of the polyethylene surface due to
Peter Herberts, MD, Goteborg, Sweden (n) multi-directional motion. Cross-linking dramatically reduces
Kajsa Erickson, Goteborg, Sweden (n) wear under physiologic loads and motion. The RSA and clinical
Karin Lindborg, Goteborg, Sweden (n) study has confirmed that no detectable wear occurred during an
average 6.6 years of clinical use. There is so far no periprosthetic
Karin Pettersson, Goteborg, Sweden (n)
osteolysis and have been no revisions related to polyethylene
This exhibition aims to demonstrate the evolution of data wear. Retrieval analysis has confirmed that little wear has
recording in the Swedish Hip Arthroplasty Register and its effects occurred after in vivo use. A series of translational research span-
on the outcome analysis. The Swedish Hip Arthroplasty Register ning over 20 years has resulted in a documented improvement
was started in 1979. From the beginning details about any reop- in the clinical outcome of THR patients.
eration procedure have been available by analysis of individual
case records. In 1992 all primary THR, previously reported as SCIENTIFIC EXHIBIT NO. SE04
aggregated data from each hospital, were identified on the indi-
vidual level including demographic data such as diagnosis (ICD ◆Metal Ion Release Following Metal-on-Metal
codes). In 1999 each implant and its part was recorded in terms Surface and Total Hip Arthroplasty: A Randomized
of article number. In 2001 a new follow-up model was intro- Trial
duced including EQ5D and patient satisfaction. In a nationwide
Pascal-Andre Vendittoli, MD, Montreal, Canada
study of reoperation due to periprosthetic fractures over the
entire period (from 1979) we have been able to obtain a more (a, e – Zimmer, Smith and Nephew, a – Stryker)
detailed analysis of prognostic factors since 1992, enabling more Martin Lavigne, MD, Montreal, Canada
firm recommendations to the profession. In the cohort operated (a, e – Zimmer, Stryker, Smith and Nephew)
between 1992 and 2004 we studied reasons for an observed Sophie Mottard, MD, Saint Lambert, Canada
increasing incidence of early revisions because of dislocation. (a – Zimmer, Stryker, Smith and Nephew)
Feedback of the results from this analysis to the profession seems Roy Alain, MD, Montreal, Canada
to be one reason for decreasing incidence during 2005. In the (a, e – Zimmer, Stryker, Smith and Nephew)
cohort operated 1999 and later we studied the influence of stem
Improved factors influencing component wear with regards to
size, neck length and offset on the early revision rate of 3
bearing surfaces, metallurgy, tribology, and manufacturing tech-
cemented stems. It turned out that such factors had an influence.
nology allowed reintroduction of metal-on-metal (MOM) artic-
The new follow-up model has enabled an improved surveillance
ulation in total hip arthroplasty (THA) and surface replacement
of the quality of the procedure and analysis of cost-effectiveness
arthroplasty (SRA). The purpose of this study is to describe and
on hospital, regional and national levels. The continuous
compare chromium and cobalt ion concentrations measured in

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

improvement of data recording was supported by the profession
different mediums following MOM hip arthroplasty One
and has resulted in further improvement of the overall quality of
hundred and twenty four hips were randomized to receive either
THR surgery.
uncemented titanium THA with 28mm MOM articulation
(CLS/Allofit/Metasul, Zimmer, USA) or MOM SRA (Durom,
SCIENTIFIC EXHIBIT NO. SE03
Zimmer, Warsaw). Tribologic factors influencing wear reviewed
The Development of Highly Cross-linked included cast/forged CrCo and components carbon content,
Polyethylene for THR sphericity, surface roughness and clearance. Samples of whole
Charles R Bragdon, PhD, Boston, MA (a, c – Zimmer) blood, serum and erythrocytes were collected preoperatively and
postoperatively at three months, six months, one year and two
Murali Jasty, MD, Boston, MA (a, c – Zimmer)
years. Chromium and cobalt concentrations were measured
Orhun K Muratoglu, PhD, Boston, MA (a, c, e – Zimmer) using a high-resolution, sector-field, inductively-coupled plasma
Harry E Rubash, MD, Boston, MA (a – Zimmer) mass spectrophotometer (HR-SF-ICP-MS). Data analysis will be
Andrew A Freiberg, MD, Boston, MA (a – Zimmer) presented to help the reader to better understand the different
Dennis W Burke, MD, Boston, MA (a – Zimmer) measuring methods and units and data spreading. In compar-
William H Harris, MD, Boston, MA (a, c – Zimmer) ison to the preoperative levels, postoperative whole blood metal
Henrik Malchau, MD, Boston, MA (a – Zimmer) ion levels increased significantly for all elements by a factor of
The clinical use of a new highly cross-linked polyethylene for 1.5 (Cr) and 5.2 (Co) in the SRA group, and 1.6 (Cr) and 5.5
THR, introduced in 1998, has become widespread. The process (Co) in the THA group. A significant difference was found
of clinical research, retrieval analysis, experimental invention between whole blood, serum and erythrocytes concentrations of
and validation, and over 5 years of clinical experience is Cr (p=0.001) and Co (p<0.001). Pearson’s correlation coeffi-
presented. A multiplicity of techniques was required for this cients between the three mediums were over 0.92. For Cr and
development project, including: Clinical and histological studies Co, the average ratios of serum and erythrocytes over whole
conducted to discern the etiology of periprosthetic osteolysis; blood were respectively 1.3 and 0.8. At one year, whole blood
Retrieval analysis of polyethylene components performed to metal ions levels were: Cr 1.55 umol/L (SD 0.91, min 0.4, max
understand the mechanism of wear; Ways of reducing polyeth- 4.5) and Cr 1.62 umol/L (SD 0.73, min 0.4, max 3.2) and Co
ylene wear were investigated and developed; Sophisticated hip 0.65 umol/L (SD 0.33, min 0.23, max 2.09) and Co 0.88 umol/L
simulators and wear screening devices were created; RSA was (SD 0.48, min 0.23, max 2.30) for the SRA and THA respectively
used to quantify wear in vivo; An average 6.6 year clinical study (Cr p=0.690; Co p=0.01). The chromium and cobalt levels
on 179 primary THR using highly cross-linked polyethylene has found in the THA and SRA groups were comparable. The data

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
419
PPSE 07:Layout 1 1/12/07 1:41 PM Page 420

spread (SD) and the proportions of outliers in the two groups findings of numerous single institutional prospective studies
were very small. We believe that the similar findings between the aimed at elucidating the etiology of hypoxia following TJA, the
THA and SRA groups are encouraging and are resultant of mode of presentation of pulmonary embolism (PE), and iden-
favourable manufacturing and tribologic factors. tification of hypoxic situations that warrant medical work up. A
cohort of 14,096 patients was studied. Using prospectively
SCIENTIFIC EXHIBIT NO. SE05 collected data since the year 2000, specific effort was made to
Improved Fixation with Locking Acetabular Shells identify presenting symptoms or signs that were indicative of an
important clinical event such as PE. The potential association
and Threaded Screws between the size and location of PE and the mode of presenta-
Wayne M Goldstein, MD, Morton Grove, IL (a – DePuy, tion was also sought. One study included 1,654 TJA; all signifi-
Smith & Nephew, c – DePuy, Smith & Nephew, Innomed) cant episodes of desaturation during hospitalization were
Alexander Gordon, MD, Highland Park, IL (n) identified. Detailed data on these patients were collected.
Patrick Aldinger, BSME, Morton Grove, IL (n) Another study sought to determine the incidence and the rise in
Abraham Salehi, PhD, Memphis, TN (n) the incidence of hypoxia and PE in the studied cohort over the
recent years. Another prospective study using continuo pulse
Jeff Shea, Memphis, TN (n)
oxymetry monitoring over a 48 hour period, evaluated the inci-
Jill Branson, RN, Kildeer, IL (n) dence of postoperative hypoxia in 42 patients receiving patient
Kimberly A Berland, CST, Warrenville, IL (n) controlled analgesia (PCA) after joint replacement. From 14,096
Christopher Simmons, BS, Morton Grove, IL (n) hip and knee replacements, 144 patients were confirmed to have
Enhanced stability of acetabular shells is desirable in acetabulum PE. In this cohort the clinical presentation of PE was nonspecific
replacement during total hip arthroplasty (THA). We have noted and highly variable ranging from mild dyspnea to catastrophic
this to be a problem in two revisions and one primary where a hemodynamic collapse. Common clinical signs and symptoms,
good press-fit was not achieved, and multiple screws were used. as well as changes in vital signs have a low sensitivity for diag-
These conventional cups rotated vertically, as they were allowed nosis and do not correlate with severity of disease as determined
angular motion by the ability of the screws to all change angles. radiographically. Although blood gas studies demonstrated a
In this unstable situation, with lack of press-fit, a cage (which is significant decrease O2 saturation and PaO2 for the presentation
less than optimal long-term) may be required. Historically, the of PE, the degree of arterial desaturation did not correlate with
concept of locking screws has produced favorable results in size or location of embolus. Clinically significant hypoxia after
trauma plates as all screws must fail simultaneously for pull-out TJA presented in 4.5% of the 1654 patients. Serious etiology,
to occur. The use of locking acetabular shells with threaded defined as pulmonary embolism, pulmonary edema and pneu-
screws was evaluated to determine if there is an improvement in monia were identified in 41% of these patients. The majority
fixation. Screw holes in the acetabular shell and cancellous screw (>70%) of patients having regional anesthesia and PCA exhib-
heads were each threaded. Torsional stability testing was ited some degree of hypoxia on the first postoperative night
performed (n=5) in order to compare a shell utilizing locking following TJA when monitored by continuous pulse oximetry.
screws to a standard shell under more consistent and repeatable Although close monitoring of all patients with hypoxia is
conditions. Porous foam blocks were used to simulate the acetab- warranted, only those with persistent or dramatic oxygen desat-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

ulum. The tests involved reaming a cavity 1mm larger than the uration may require further investigation. Based on the findings
shell and inserting one screws. The shell was rotated one cycle of this study, we propose an algorithm for the management of
from +10 to -10 degrees. These modified cups were used in nine hypoxia following total joint arthroplasty.
clinical situations in revision (6) or inadequate press-fit (4). Tests
were repeated using two screws. Clinically, all acetabular cups SCIENTIFIC EXHIBIT NO. SE07
were stable for full weight bearing at six weeks. In the biome- ◆Particle Analysis of Improved Polyethylene Such
chanical study, the shell with locking screws obtained statistically as Hylamer, 100Mrad Irradiated PE and Modern
higher (p<0.05) torsional resistance than the standard shell in the
overream condition. Clinical evaluation and laboratory testing XLPE
indicated enhanced stability when utilizing the shell with Hiroyoshi Iwaki, MD, Osaka, Japan (n)
threaded screws. This device might be indicated in revisions in Akio Kobayashi, MD, Osaka, Japan (n)
place of a cage or where a press-fit cannot be achieved. Yukihide Minoda, MD, Hyogo, Japan (n)
Ryo Sugama, MD, Osaka, Japan (n)
SCIENTIFIC EXHIBIT NO. SE06
Inori Fumiaki, MD, Osaka, Japan (n)
Management of Hypoxia Following Total Joint Kentarou Iwakiri, MD, Osaka, Japan (n)
Arthroplasty Ohta Yoichi, MD, Osaka, Japan (n)
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) Takaoka Kunio, MD, Osaka, Japan (n)
Pulido Luis, MD, Philadelphia, PA (n) Wear particles and consequent osteolysis critically determines
Luke Austin, MD, Philadelphia, PA (n) the long-term results of joint replacements. Therefore it is impor-
Michael Williams, MD, Philadelphia, PA (n) tant to characterize wear particles in vivo. Modifications of
Grodecks Woldzimierz, MD, Philadelphia, PA (n) UHMWPE have been developed to reduce wear such as Hylamer,
100Mrad irradiated PE by Oonishi and recent highly cross -
Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
linked polyethylene (XLPE), which were analyzed in the present
Seth Grossman, BS, Philadelphia, PA (n) study. Five cups with 2 Hylamer, 2 100Mrad irradiated polyeth-
Hypoxia is a relatively common event following total joint ylene and one XLPE (Crossfire: Stryker) were revised due to
arthroplasty (TJA). As a result of better nursing care and the aseptic loosening and joint fluids were aspirated from six well-
liberal use of intrathecal opioids in recent years, a strict postop- functioning patients with XLPE (Longevity: Zimmer).
erative surveillance consisting of frequent pulse oximetry meas- Polyethylene particles were extracted from tissues or joint fluid
urements has been implemented. This exhibit will present the and analyzed. ECD was 1.07mm and 1.16 and Aspect ratio (AR)

420 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 421

was 1.99 and 2.07 in Hylamer. ECDs and ARsof the rest were none of our patients had histologic features pointing to allergic
very similar. Number of particles varied from5.33 x107 to type metal sensitivity reactions, a few rare cases have been veri-
7.0x109. Hylamer particles were larger, more elongated in shape fied in retrievals sent from Australia and Europe.
and a much more in tissue than 100Mrad polyethylene and
XLPE. 100Mrad polyethylene and XLPE (Longevity and SCIENTIFIC EXHIBIT NO. SE09
Crossfire) were very similar in shape, less, a little smaller and Instability Following Total Hip Arthroplasty:
much rounder in compared with our previous result of conven-
tional polyethylene. We clearly showed modification of
We Have Come Far
UHMWPE leaded to different morphology of particles and these Camilo Restrepo, MD, Philadelphia, PA (n)
different features might have different tissue reaction. Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
Elie Ghanem, MD, Philadelphia, PA (n)
SCIENTIFIC EXHIBIT NO. SE08 Aidin Eslam Pour, MD, Philadelphia, PA (n)
◆10 Years of Experience with Metal-on-Metal William J Hozack, MD, Philadelphia, PA (e – Stryker)
Hybrid Hip Resurfacing: A Review of 1000 Conserve Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
Instability following total hip arthroplasty is a relatively
Plus
common complication. Although majority of dislocations can
Harlan C Amstutz, MD, Los Angeles, CA be managed nonoperatively, there may be some patients who
(a, b, c, e – Wright Medical Technology) require surgical intervention to address this complication. This
Michael J LeDuff, MA, Glendale, CA scientific exhibit reports the findings of numerous studies
(b – Wright Medical Technology) conducted at this institution related to the problem of insta-
Patricia A Campbell, PhD, Los Angeles, CA bility. The computerized database on over 40,000 patients has
(a, b – Wright Medical Technology) been evaluated to identify patients who developed instability
Frederick Dorey, PhD, Los Angeles, CA (n) following THA. The first study evaluated the incidence, the mode
of presentation, the risk factors, and the outcome of treatment
Joshua J Jacobs, MD, Chicago, IL
for dislocation in a cohort of 320 patients. The second prospec-
(a – Wright Medical Technology) tive study evaluated the outcome of surgical intervention for
Anastasia K Skipor, Chicago, IL recurrent instability in a cohort of 93 patients. The third prospec-
(a – Wright Medical Technology) tive study evaluated the etiology and the outcome for treatment
Hip resurfacing is currently a very fast growing procedure world- of late instability. Finally, a prospective study was conducted to
wide. The imminent FDA release of these devices should prompt evaluate the role of various patient restrictions in preventing
great demand for information on the clinical results of the instability following primary THA. Instability occurs in 1.2% of
ongoing experimental series. The present study reviewed 1000 patients after primary and 8% after revision arthroplasty. Eighty
hips in 838 patients who received a hybrid metal-on-metal percent of dislocations following primary THA are single
resurfacing (ConserveÒ Plus) at a single institution. The average episodes and can be treated nonoperatively. Subtle component
age of the patients was 49.9 years; 73% of the study group were malpositioning is the most common cause of recurrent insta-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

male. The study group had a mean follow-up of 5.1 years (range: bility. Instability following revision THA may be more of a
1.0 to 10.2 years) with excellent clinical results. Indications, problem with over 50% requiring surgical intervention. Late
contra-indications and challenging cases for the procedure were instability may be the result of impingement and polyethylene
reviewed based on the analysis of implants retrieved from 1 wear. Constrained liner is successful in addressing recurrent
week to 10 years postoperatively. An update of the current instability in 90% of patients. Acetabular loosening may occur
surgical technique will be demonstrated using audio-visual with the use of constrained liners in 35% of patients at five years.
support. There were 30 revisions: Nine neck fractures, seventeen Instability following THA may be on the decline. The introduc-
femoral loosenings, 2 sepses, and one case each of postoperative tion of alternative bearing surface, allowing the use of larger
acetabular component protrusio and recurrent subluxation. femoral heads, better patient education, and improved surgical
Complication rates other than dislocation and fracture of the techniques (such as repair of the posterior capsule) may have all
femoral neck were comparable between resurfacing and conven- imparted beneficial influence in reducing this dreaded compli-
tional THR. The incidence of femoral neck fracture was low but cation. We propose an algorithm for prevention and treatment
can still be reduced with proper patient selection and surgical of instability following primary and revision THA.
technique. Retrieval analysis revealed that the implants were
sometimes left incompletely seated. This error puts the femoral SCIENTIFIC EXHIBIT NO. SE10
neck at risk in several ways, and histological analysis showed that Using More Severe Test Methods for Improved
fractures often occurred through areas of weak, healing new
bone. Component loosening after metal-on-metal resurfacing Performance Predictions of Joint Replacements
has been significantly reduced and acetabular component loos- John Bowsher, PhD, Loma Linda, CA (n)
ening has not happened in this series. Femoral component loos- Thomas Kent Donaldson, MD, Colton, CA (n)
ening has been the main mode of failure so far, and was Ian C Clarke PhD, Loma Linda, CA (n)
associated with inadequate size and quality of the fixation area. One criticism of prior laboratory wear studies of total joint
An improved surgical technique in the femoral preparation has replacements is that traditional test modes involved pristine
significantly reduced loosening failures. Prospective studies of bearing surfaces run under idealistic loading and continuous
patients receiving MMSA components have shown that systemic motion. Thus clinical failures were not always identified owing
cobalt and chromium levels increase, especially in the first year to the lack of adequate severe testing. To address this concern,
postoperatively, but the levels are often comparable to those recent studies have introduced more severe wear models for the
measured in patients with standard hip replacements. Although hip and knee bearings, all showing improvements in simulating
clinical wear. These models will become the foundation for
simulating wear performance in the rapidly growing population

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
421
PPSE 07:Layout 1 1/12/07 1:41 PM Page 422

of high-risk patients. Severe studies used combinations of clin- costs, has to be considered when implementing conservation
ical parameters, including micro-separation, intermittent strategies with proven effectiveness to reduce the need for allo-
loading, impingement, eccentric wear-paths, vertically-tilted genic transfusion.
cups, low protein lubricants, stair climbing, fast-jogging activi-
ties, high swing-phase loads, third-body contamination and SCIENTIFIC EXHIBIT NO. SE12
backside cup wear. Micro-separation studies of all-ceramic and Status of Aluminum, Oxinium, Zirconia ad Zirconia-
all-metal hip bearings generated 2 to 10-fold increase in wear
with the formation of stripes and more closely predicted known
toughened Alumina Hip Implants in USA
clinical performance. Combined studies of damaged femoral Ian C Clarke PhD, Loma Linda, CA
balls, large ball diameters and fast-jogging cycles suggested little (a – Biomet, CeramTec, Smith and Nephew, Stryker)
wear advantage for modern-crosslinked UHMWPE’s compared Thomas Kent Donaldson, MD, Colton, CA (a – Biomet)
to conventional UHMWPE’s. Severe wear models offer improved Giuseppe Pezzotti, PhD, Loma Linda, CA
discrimination for biomaterial choices and implant designs. (a – Biomet, CeramTec, Stryker)
However, we need to develop a better understanding of which Douglas D Green, Loma Linda, CA
models offer the best predictive capabilities for each combina-
(a – Biomet, CeramTec, Smith and Nephew, Stryker)
tion of choices. This review of severe wear simulations in the hip
and knee will highlight improved understanding of design and
Paul Williams, MS, Loma Linda, CA
material performance in-vivo. (a – Biomet, CeramTec, Smith and Nephew, Stryker)
Alumina (Al) dominated ceramic implants since the 1970’s.
SCIENTIFIC EXHIBIT NO. SE11 Benefits are exceptional inertness, hardness and wear resistance.
Blood Conservation in Total Joint Arthroplasty However it is also brittle, thus subject to small but persistent frac-
ture risk (typically < 0.01%) associated with balls 28mm dia or
Luis Pulido, MD, Philadelphia, PA (n) less. High strength ytrria-zirconia was introduced in 1985 but
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) abandoned by 2002 due to unique fracture problem. In late
Rachel Trappler, Philadelphia, PA (n) 1990’s a zirconia-surfaced metal ball Oxinium was approved for
James J Purtill, MD, Philadelphia, PA (n) use on PE cups. In 2000, a zirconia-toughened alumina (ZTA)
Jay Herman, MD, Philadelphia, PA (n) was introduced in Europe (Biolox-delta) for use with ceramics
Seung Beom Han, MD, Bryn Mawr, PA (n) and PE-liners. This ZTA doubled the strength and reliability of
Sonia Chaudry, BS, Philadelphia, PA (n) alumina . FDA status-2006 is ZTA-PE approved but not ZTA-ZTA
or ZTA-Al combinations. We compared implant retrievals with
The number of total joint arthroplasties being performed world-
simulator wear studies and accompanying debris analyses.
wide is on the rise. Patients receiving TJA not infrequently
Analytical techniques included light microscopy, scanning elec-
require blood transfusion postoperatively. The aim of this scien-
tron microscopy, laser interferrometry, x-ray diffraction and
tific exhibit is to present the findings of various studies
confocal Raman microscopy techniques. Simulator test modes
performed at this institution aimed at evaluating the efficacy of
included standard walking (Paul curve) and severe testing under
commonly implemented conservation strategies such as autolo-
microseparation test mode. Aging studies utilized autoclaving to
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

gous blood donation, hypotensive anesthesia, and intraopera-

investigate hyedrothermal stability of metastable ceramics and
tive salvage systems as well as less commonly employed
several mechanical test modes were used to impact the ceramic
protocols such as the use of hemostatic agents and blood
surfaces. Studies of zirconia ball retrievals showed up to 80%
conserving agents during elective joint arthroplasty. Four studies
surface transformation at 6 to 10 years. Simulator studies did
were conducted on a cohort of 1943 patients to seek answer to
NOT predict this effect. Only the autoclave studies could show
these common questions: a) Is preoperative blood donation safe
significant transformation (20%) and mechanical modes
and does it reduce the likelihood of allogenic transfusion; b) Is
showed little effect. Microseparation (MSX) studies showed that
intraoperative cell salvage effective in reducing the need for allo-
ZTA ceramic offered 2 to 10-fold wear reduction in severe test
genic transfusion, c) do hemostatic agents have a role during
modes compared to alumina. Also considered were the zirconia
joint arthroplasty, and d) can antifibrinolytic agents such as
phases in ZTA composites. Simulator study ZTA-ZTA ceramics
aprotinin, or similar agents, be administered safely to reduce the
reported > 20% phase transformation on ball and cup surfaces,
need for postoperative transfusion. Preoperative autologous
but different effect compared to zirconia balls. For the first time
blood donation (PAD) in total joint replacement was studied in
in 35-year implant history, ceramic alternatives are becoming
a cohort of 922 patients. Autologous blood donation reduced
available in varied ball diameters using alumina, Oxinium,
the need for allogenic transfusion in the THA group (p<0.05)
Zirconia and Zirconia-toughened Aluminas. With ceramics
but had no influence on the incidence of allogenic transfusion
offering the ultimate, low-wearing, unscratchable bearing
in the TKA group. The use of intraoperative blood salvage
surface, this offers considerable potential for improved designs.
(IOBS) was followed prospectively in 251 patients that under-
Care must be taken to ensure the safety/stability of ceramics for
went complex hip revision surgery. Salvaged blood was only
intended decades of use in-vivo. Thus our study compared the
sufficient for reinfusion in 52% (131 cases). The average blood
performance of metastable ceramics to the historical alumina
loss and reinfusion volume in the latter group was 842ml and
standard shown to be totally inert after 30-years use in patients.
259.9ml, respectively. As part of two randomized, placebo-
controlled trial, a hemostatic agent and an antifibronylitic agent
were found to significantly reduce the intraoperative blood loss
and the subsequent need for postoperative transfusion. Blood
conservation during total joint arthroplasty is becoming an
increasingly important issue. The balance between risk versus
benefit, effectiveness, availability of supplies, and the increasing

422 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 423

SCIENTIFIC EXHIBIT NO. SE13 uated the value of aggressive wound management which
Status of Zirconia Hip and Knee Implants in USA included surgical debridement of the wound on postoperative
day 7 for patients with persistent wound drainage and compare
Thomas Kent Donaldson, MD, Colton, CA (n) the outcome to administration of oral antibiotics. The incidence
Ian C Clarke PhD, Loma Linda, CA (n) of persistent wound drainage after TJA was 4.5% in this cohort.
Giuseppe Pezzotti, PhD, Loma Linda, CA (n) A significant association between wound drainage/hematoma
Douglas D Green, Loma Linda, CA (n) formation and later PPI was found. The mean INR of patients
Sharon Brown, BS, Colton, CA (n) with wound drainage was significantly higher than those
Michael D Ries, MD, San Francisco, CA (n) without drainage. The intraoperative deep tissue culture was
Paul Williams, MS, Loma Linda, CA (n) positive in 75% of patients with persistent wound drainage who
received surgical debridement. The incidence of PPI was signifi-
This study reviews the efficacy of the important high-strength
cantly higher in patients who did not undergone surgical
ceramic zirconia as used in total hip and total knee arthroplasty.
debridement and continued to have wound drainage. Persistent
We have mapped the surface changes on zirconia balls retrieved
wound drainage is not an uncommon event after elective TJA.
from revision operations in Australia, New Zealand, Japan,
Aggressive anticoagulation seems to be an important factor in
France, UK and USA. Survival times ranged from 1 to 11 years.
causing this postoperative problem. It appears that patients with
We also studied zirconia/polythylene and zirconia/alumina
persistent wound drainage may be at higher risk of peripros-
combinations by hip and knee simulator wear techniques. Some
thetic infection. Aggressive surgical management of wound
zirconia balls retrieved from the field had roughness values
drainage may be indicated for some patients.
increased from 0.005um to 0.25um, i.e.: an increase of 50-times.
SEM studies showed that this was due to cratering of the aticular
SCIENTIFIC EXHIBIT NO. SE15
surface. Raman spectroscopy showed that this was due to a phase
transformation from tetragonal to monoclinic that varied from Radiographic Evidence of Acetabular Dome Gap-
20% up to 80%. Maximum predicted monoclinic by 10 years Filling Following the Use of a Porous, Trabecular
was supposed to be < 10%. Simulator studies predicted very low
wear and did not discover any monoclinic changes in either THR
Metal, Monoblock Acetabular Component
or TKR. The zirconia/polythylene and zirconia/alumina THR George A Macheras, MD, Athens, Greece (n)
combinations appear to have been discontinued, certainly by Athanasios Kostakos, MD, Neo Psyhiko, Greece (n)
2002 era. Our studies showed a greatly accelerated transforma- Stephanos Koutsostathis, MD, Athens, Greece (n)
tion from tetragonal to monoclinic that had not been predicted Topkas Athanasios, MD, Athens, Greece (n)
for solid zirconia balls. It also showed that laboratory studies are Kostas Kateros, MD, Athens, Greece (n)
of little predictive value for biomaterials that can age in-vivo Robert W Eberle, Apex, NC (e – Zimmer)
(such as zirconia balls and Hylamer polyethylene cups). The Survival of cementless acetabular components in total hip
information on zirconia knees is not in yet, so this may be a arthroplasty depends on design, manufacturing and initial fixa-
more successful clinical experience than zirconia femoral heads. tion stability. We radiographically identified gaps between host
In addition, the ceramic-surface heads and knees made with bone and acetabular component dome. The purpose of this

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

zirconium metal already exist in monoclinic phase so as to be prospective study was to evaluate the osteoconductive and
stable in-vivo. possibly osteoinductive properties of trabecular metal and the
possibility of bridging of gaps up to 5mm. During 1998, 82
SCIENTIFIC EXHIBIT NO. SE14
consecutive patients (86 hips) underwent primary THA using
Management of Wound Drainage After Total Joint the elliptical press-fit trabecular metal monoblock cup (TMT,
Arthroplasty Zimmer) by the senior author. Patients were followed up at 6,
Elie Ghanem, MD, Philadelphia, PA (n) 12, 24 weeks, 12 months and annually thereafter to a minimum
of 7 years. Defined radiographic study was performed. EBRA
Aidin Eslam Pour, MD, Philadelphia, PA (n)
method, which contains an algorithm that excludes radiographs
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) exceeding the limits of patient positioning errors was used, thus
James J Purtill, MD, Philadelphia, PA (n) avoiding preanalytical errors. All hips were followed up for mean
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker) period of 7.3 years. No patient was lost to follow-up, no cup was
William J Hozack, MD, Philadelphia, PA (e – Stryker) revised, no radiolucencies and no other complications were
Fereidoon M Jaberi, MD, Philadelphia, PA (n) observed. Of the original cohort, 25 hips at the immediate post-
Wound drainage is a common and a potentially concerning operative radiograph had evidence of gap between the outer
event following total joint arthroplasty (TJA). Although oral surface of the cup and acetabular host bed, which ranged 1 to
antibiotics are commonly administered to patients with 5mm. These 25 hips were additionally studied for cup migration
persistent drainage, the value of such common practice has not through 2 years using EBRA method. At 24 weeks postopera-
been evaluated. Further, the association between wound tively, no acetabular cup with initial evidence of gap had
drainage and potential for periprosthetic infection has not been migrated and all gaps were filled with bone Bridging interface
proven. The goal of this exhibit is to: a) determine the incidence gaps up to 5mm using trabecular metal monoblock cup indi-
of wound drainage following TJA in a single institution; b) cates strong osteoconductive and possibly osteoinductive
examine the potential association between wound drainage and biomaterial properties.
development of PPI, and c) propose an algorithm for manage-
ment of persistent drainage. The incidence of wound drainage in
prospective cohort of 5200 patients receiving TJA in a single
institution was determined. In a well-matched case controlled
study containing 234 patients the association between wound
drainage and PPI was examined. A third prospective study eval-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
423
PPSE 07:Layout 1 1/12/07 1:41 PM Page 424

SCIENTIFIC EXHIBIT NO. SE16

Repair and Reconstruction of the Greater
Trochanter in Revision Total Hip Arthroplasty
Leo A Whiteside, MD, Saint Louis, MO
(a, b, e – Whiteside Biomechanics, Inc.)
Repair and reconstruction of the greater trochanter requires a
system that achieves rigid fixation of fragile bone stock, which
often is just a fragmented cortical shell. This fixation must be
done with a mechanism that does not disrupt the blood supply
and soft-tissue attachments to the bone fragments, and leaves a
smooth surface under the fascia lata and gluteus maximus. A
low-profile cable with three tensioners used simultaneously
provides a reliable, cost-effective, and efficient means of
achieving these goals. After curettage and grafting of the
trochanteric cyst, a cable is passed, with minimal dissection,
around the femoral shaft just below the lesser trochanter, and
tightened partially. Two cables are passed under the circumfer-
ential cable, then around the greater trochanter using a
Burlischer clamp or other suitable instrument to pass the cable
subperiosteally with multiple passes. First the circumferential
cable is tightened partially, then the three cables all are tightened
down sequentially until motion in the trochanteric fragments is
minimal and the entire structure moves as a unit with the femur.
The vastus lateralis is closed over the cables and crimps. This
gives a smooth surface that glides under the fascia lata without
abrasion. Eleven hips (11 patients) had reconstruction of the
greater trochanter using this technique in conjunction with revi-
sion surgery for the femoral or acetabular component. During 6
to 35 month follow-up, none have failed and abductor strength
returned in all cases. This simple technique offers an inexpensive
and reliable method to solve a difficult problem in revision
THA.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP

424 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 425

A D U LT R E C O N S T R U C T I O N K N E E
PAPERS PAPER NO. 002
Patellofemoral Arthroplasty: A Multi-Center Study
with Minimum Two-Year Follow Up
PAPER NO. 001 Wayne B Leadbetter, MD, Potomac, MD (a, b, c, e –
Patellofemoral Arthroplasty Results in Young Stryker)
Patients (<45 Years ) Frank R. Kolisek, MD, Indianapolis, IN (a, b, c, e – Stryker)
Wayne B Leadbetter, MD, Potomac, MD (a, b, e – Stryker) Richard L Levitt, MD, Coral Gables, FL (b, c – Stryker)
Christopher Ackroyd, FRCS, Bristol, United Kingdom Andrew F Brooker, MD, Amarillo, TX (n)
(a, b, c, e – Stryker) David R Marker, BS, Baltimore, MD (n)
Abstract: Patellofemoral arthroplasty (PFA) has gained renewed Michael A Mont, MD, Baltimore, MD (a, b, c, e – Stryker)
acceptance in the salvage of painful isolated patellofemoral Abstract: Recently, patellofemoral arthroplasty (PFA) has gained
arthritis and severe chondrosis. However, it’s role in midlife and increased acceptance as a salvage treatment for isolated
younger patients with symptomatic patellofemoral degenerative patellofemoral arthritis and symptomatic severe chondroma-
disease is not defined. This paper reviews our experience with lacia. To date, relatively few reports have documented results
patellofemoral arthroplasty in patients 45 years old or younger with the present generation of prostheses; many of these studies
who have failed extensive alternative treatment, had significant have included fewer than 20 knees or have relatively high loss of
disability, and were considered too young for or refused a total follow up. This multicenter investigation describes the results
knee replacement. A combined series of consecutive patients utilizing PFA with outcome reported at a minimum of two year
who were 45 years old or younger that had undergone PFA were follow up. Data was analyzed from four centers that have contin-
studied by chart review, an analysis of prospectively collected uously performed PFA for isolated patellofemoral degenerative
outcome data, and by interview or re-exam. No patients were disease since January 2001. All patients had failed an extensive
lost to follow up. Diagnoses leading to PFA included non-operative treatment regimen and/or exhausted conven-
patellofemoral malalignment, patellofemoral dysplasia, idio- tional alternative surgical treatments. Patients were included if
pathic or post traumatic isolated chondral degeneration. Novel they had a minimum two year follow up. Patient demographics,
indications for PFA included failed anteromedialization tibial associated complications, results of radiographic analysis, and
tubercle osteotomy and post patellectomy pain . Demographic the reasons for revision surgery were recorded. Functional and
data, complications, radiographic analysis of the prosthesis and objective outcomes were assessed using the Knee Society rating
remaining joint, and reasons for revision were recorded. system. Patients were also stratified by whether the PFA was
Functional and objective outcome was assessed using the Bristol straightforward or required ancillary procedures (such as, lateral

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Pain Score, Bristol Movement Score, Melbourne Patellar Score, release, tibial tubercle transfer, extensor realignments,
and Oxford Knee Score. Finally, technical issues and selection osteotomies, cartilage restoration or chondroplasty) to see if
failure was critiqued. There were a total of 32 patients (42 these had any affect on final outcome. A total of 55 patients (59
knees), which included 28 women and 4 men, with a mean age knees) were treated with PFA. There were 10 men and 45 women
of 37 years (range, 25-45 years) operated between 1996 and who had a mean age of 69 years (range, 26 to 75 years). At a
2005. Follow up was a minimum of 2 years in 20 knees; 3 years mean follow up of 3 years (range, 2 to 6 years), overall prosthetic
in 17 knees; and over 5 years in 5 knees. Complications survival and preservation was 93%. There were 45 patients
included: residual pain or mechanical symptom 4 (9.5%); (82%) with good or excellent clinical results (Knee Society score
disease progression 3 (7.1%); maltracking/subluxation 2 of 80 points or more). Complications included: two arthrofi-
(4.7%); arthrofibrosis 1 (2.3%); component revision 1 (2.3%); brotic knees (3.6%), two patellar tendon ruptures from falls in
revision to total knee replacement 1(2.3 %). There was no inci- the perioperative period (3.6%), one lateral retinacular impinge-
dence of infection, prosthetic loosening, or component wear. ment (1.8%), five persistent effusions (9 %), and four patients
Problems included residual maltracking 2 (4.7%); selection with persistent pain (7.2%). The four patients presenting with
error 1 (2.3%); patellar overstuffing 1 (2.3%); femoral compo- persistent pain and progressive disease required revision to a
nent malrotation 1 (2.3%); At 2 years post-operative the Bristol total knee replacement. There were ten patients (18.2%) who
Pain Score increased 28.5 points to 35 out of 40 points. Mean underwent re-operation for any reason. Radiographic findings
knee range of motion on the Bristol Movement Scale increased did not show component loosening or progressive wear. Patients
in flexion from 108 to 120 degrees. The Melbourne Patellar Score who required ancillary procedures in conjunction with PFA were
increased 20.5 points to 30 out of 30. The Oxford Knee Score not adversely affected. PFA as a salvage procedure for isolated
increased from 19 to 43 out of 48. Symptomatic patellofemoral patellofemoral degenerative disease was successful in 82% of
arthritis and and chondral degeneration remain a challenging patients at a short-term follow up. Patients requiring prior or
management problem especially in the face of failed prior oper- coincident ancillary procedures often had a successful outcome
ative treatments in the younger patient. When non-operative if these measures aided in the soft tissue balancing of
methods and other conventional surgical options are exhausted, patellofemoral tracking or contributed to further conservation of
selective patellofemoral arthroplasty can be a useful salvage the remaining joint. The authors are encouraged by the excellent
solution to avoid patellectomy or total knee replacement. early results of these procedures and await long-term follow up
to see if these promising results will be maintained.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
425
PPSE 07:Layout 1 1/12/07 1:41 PM Page 426

PAPER NO. 003 post engagement occurs, the higher is the maximal knee flexion.
TKR for Isolated Patellofemoral Osteoarthritis in The factors that affect cam-post engagement timing should be
established so that the flexion capability of the knees can be
Young Patients: The Procedure of Choice enhanced.
John B. Meding, MD, Mooresville, IN (a, e – Biomet)
E Michael Keating, MD, Mooresville, IN (a, e – Biomet) PAPER NO. 005
Philip M Faris, MD, Mooresville, IN (a, e – Biomet) The Incidence of Patellar Clunk in a Modern
Michael E Berend, MD, Mooresville, IN (a, e – Biomet) Posterior-Stabilized Knee Design
Merrill A Ritter, MD, Indianapolis, IN (a – Biomet) Jess H Lonner, MD, Philadelphia, PA (a, c, e – Zimmer)
Robert A Malizak, MD (a – Biomet) Jeff Jasko, MS, Phildelphia, PA (n)
Abstract: To evaluate the results of total knee replacement in Hari Bezwada, MD, Philadelphia, PA (a)
younger patients with isolated patellofemoral osteoarthritis.
David George Nazarian, MD, Philadelphia, PA (a, c, e)
From a study base of 11,555 primary total knee replacements,
thirty-three arthroplasties were performed in twenty-seven Robert E. Booth, Jr MD, Philadelphia, PA (a, c)
patients less than sixty years of age (average age, 52 years) with Abstract: Patellar clunk can occur after posterior stabilized (PS)
isolated patellofemoral osteoarthritis. 78% of patients were total knee arthroplasty (TKA) but is more prevalent with partic-
female. A cemented PCL-retaining prosthesis was used in twenty ular designs. This series documents the incidence of patellar
three (70%) knees. All patients were followed for at least two clunk in 300 consecutive TKAs with either an Insall-Burstein II
years (average follow-up, 6.2 years). Average Knee Society knee (IB-II) or a Nexgen LPS design. 150 consecutive IB-II PS TKAs
scores improved from 49 pre-operatively to 88 at final follow- were compared to a second consecutive series of 150 Nexgen LPS
up. Similarly, average pain scores improved from 5 to 44 with TKAs. The surgical technique was identical. All patellae were
over 85 % of knees rated with minimal or no pain. Function and resurfaced. Postoperative joint-line elevations and clinical scores
stair scores averaged 83 and 42, respectively, at final follow-up. were compared between groups. In patients presenting with
There was one case each of a one millimeter radiolucency in patellar clunk, the synovial nodule was arthroscopically
patellar zone 2, femoral zone 1, and tibial zone 4. There were no debrided from the undersurface of the quadriceps tendon.
infections, revisions, re-operations, manipulations, patellar Follow up averaged two years. The IB-II group had a 4% inci-
instability, or component loosening. To become a viable treat- dence of patellar clunk (average onset: 13 months after TKA),
ment option for isolated patellofemoral osteoarthritis in young compared to zero incidence in the NexGen group (p=0.03). In
patients, the results of patellofemoral arthroplasty should be at IB-II patients, average postoperative Knee Society Clinical and
least as good as the results of total knee replacement in these Function Scores were 81 and 63, respectively. Range of motion
patients. These results should question the use of patellofemoral was 115 degrees. In Nexgen patients, average Knee Society
arthoplasty in any patient. Clinical Scores were 82, Function Scores 54, and average motion
110 degrees. Differences between groups were not significant.
PAPER NO. 004 Although joint-line elevation was observed within groups
(p<0.001 for both), there was no statistical difference between
In-vivo Cam-Post Interaction and Knee Flexion in a
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

them (p=0.556). Design features of the NexGen TKA (including

Posterior-Substituting Total Knee Arthroplasty an extended and deepened trochlear groove, and raised lateral
Guoan Li, PhD, Boston, MA (a – Zimmer) flange) help resolve the problem of patellar clunk. The incidence
Jeremy F Suggs, BS, Boston, MA (n) observed in IB-II patients is not attributable to greater joint-line
George R Hanson, BS, Boston, MA (n) elevation. Meticulous surgical technique and use of an implant
Young-Min Kwon, MD, Boston, MA (n) of sound design can reduce the tendency for patellar clunk.
Andrew A Freiberg, MD, Boston, MA (a – Zimmer) PAPER NO. 006
Harry E Rubash, MD, Boston, MA (a, c – Zimmer)
Abstract: No quantitative data have been reported on the effec
Kinetic Performance Comparison for Traditional
tiveness of the cam-post mechanism during in-vivo flexion in a and High Flexion TKA
PS TKA. We investigated the cam-post engagement during in- Giles R Scuderi, MD, New York, NY (n)
vivo weight-bearing knee flexion of TKA patients using a dual- Richard D Komistek, PhD, Knoxville, TN (a – Knee Society)
orthogonal fluoroscopic imaging technique. Twelve patients Douglas A Dennis, MD, Denver, CO (n)
with a PS TKA were recruited. Each patient performed a single leg Chitranjan S Ranawat, MD, New York, NY (n)
lunge from full extension to maximal flexion as images were
Adrija Sharma, Knoxville, TN (a – Knee Society)
recorded using the fluoroscopic system. The in-vivo knee posi-
tion at each targeting flexion angle was then reproduced using Mohamed Mahfouz, PhD, Knoxville, TN (a – Knee Society)
the 3D TKA models and the fluoroscopic images. The cam-post Fei Liu, MS, Knoxville, TN (a – Knee Society)
engagement was then determined when the surface model of the Matthew Anderle, BS, Denver, CO (a – Knee Society)
femoral cam overlapped with that of the tibial post. The Abstract: Recently, patients are requesting TKAs that allow for
maximal flexion angle of all subjects was 109.1 ± 19.4°. The higher degrees of knee flexion and the surgeon to implant them
mean flexion angle at which initial cam-post engagement using smaller incisions. Therefore, manufacturers are now devel-
occured was 91.0 ± 9.0°. When dividing the patients into a low oping high flexion type TKA that are not radically different from
flexion group (maximal flexion < 109.1°) and a high flexion the more traditional ones but incorporate subtle changes in the
group (maximal flexion > 109.1°), the initial cam-post engage- geometry of the femoral and the polyethylene component radii
ment angle of the low flexion group (78.7 ± 6.7°) was signifi- to facilitate higher amounts of flexion. Some studies have
cantly lower than that of the high flexion group (90.8 ± 5.2°) demonstrated that they achieve higher amounts of flexion.
(p<0.05). The timing of the cam-post engagement was shown to However, failure, in the form of wear of the polyethylene insert,
affect the maximal flexion angles of the knee. The later the cam- still reigns as the major limiting factor in modern TKAs. As a

426 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 427

result, analyzing the contact forces and contact stresses experi- degrees in all subgroups, presenting significantly more rotation
enced in these types of implants is of great importance. in RA with mobile than other subgroups. No significant differ-
Therefore, the purpose of this study was to compare the in-vivo ence was noted between mobile and fixed in OA knees. No
kinetic performance of traditional and high flexion TKAs. For significant differences were noted regarding maximal flexion
this study, 17 subjects were analyzed under fluoroscopic surveil- angle, either. Contribution of mobile insert was observed to
lance while performing a deep knee bend activity. Five of the tibial internal rotation in RA but not in OA. No contribution was
subjects were implanted using a traditional fixed bearing TKA, noted to femoral rollback and maximal flexion angle. It could be
five with a traditional mobile bearing implant and seven with a said that mobile insert has little or no contribution at least in
high flexion fixed bearing type implant. In-vivo kinematics for non-arthritic knees.
the subjects were analyzed using a 3D to 2D image registration
technique and were input in an 3D inverse dynamics rigid body PAPER NO. 008
analysis mathematical model in order to generate the contact Polyethylene Wear and Osteolysis After Fixed-and
forces at the femoral and polyethylene interface. Based on the
transformation coordinates obtained from the previously
Mobile-Bearing Total Knees in Young Patients
described registration technique the CAD models of the femur Young-Hoo Kim, MD, Seoul, Republic of Korea (n)
and polyethylene were assembled and the interface area between Jun Shik Kim, MD, Seoul, Republic of Korea (n)
the two was measured. This interference area was assumed to be Dae-Ya Kim, MD, Seoul, Republic of Korea (n)
the contact area. Finally, the contact pressure was defined as the Abstract: The purpose of this prospective and randomized study
ratio of the contact forces and the contact areas. The medial was to evaluate clinical and radiographic results and to docu-
contact forces for all the implants were found to be similar ment prevalence of polyethylene wear and osteolysis associated
ranging from about 0.5 BW at full extension to about 2.7BW at with fixed-and mobile-bearing total knee arthroplasties in young
full flexion. The high flexion TKA however experienced slightly patients who had bilateral simultaneous total knee arthroplas-
higher values of lateral contact forces reaching a value of 1.25BW ties. Sixty-one patients who were younger than 60 years of age
at full flexion compared to the traditional TKAs, which had a (mean age, 58.3 years) received AMK fixed-bearing knee pros-
maximum value of 0.85BW at full flexion. Interestingly, thesis in one knee and a LCS mobile-bearing knee prosthesis in
however, the high flexion TKA was able to maintain a high contralateral knee. Forty-five patients were women, and 16
amount of contact area throughout the flexion cycle when patients were men. At a mean of 10.8 years postoperatively,
compared to those of the traditional bearings. This was observed patients were assessed clinically and radiographically with use of
markedly during the later half of flexion, where there was a knee-rating system of the Knee Society (KS) and The Hospital for
reduction in the contact area for the traditional bearing TKAs but Special Surgery (HSS). The prevalence of polyethylene bearing
an increase in contact area for the high flexion design TKA. As a wear and osteolysis was documented with both radiographs and
result the high flexion TKA had significantly lesser magnitudes of CT scans. The postoperative knee scores in both groups were not
contact pressures than the traditional TKA types on both the statistically different according to KS (94 vs 93 points, P=0.524)
condyles. In conclusion this study reflects that the high flexion and HSS knee scores (89 vs 87 points, P=0.422). In AMK group,
designs have similar nature of contact forces compared to the 2 knees (2%) were revised because of wear of tibial bearing and

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

traditional designs. However, the high flexion design is able to 1 knee (1%) was revised because of osteolysis in femoral
maintain higher amount of femoro-tibial conformance resulting condyles. In LCS group, 1 knee (1%) was revised because of wear
in lower contact pressures and therefore seems to offer and of tibial bearing and 1 knee (1%) was revised because of dislo-
advantage in this regard. cation of medial tibial meniscal bearing. No unrevised knee in
either group had detectable polyethylene wear or osteolysis. We
PAPER NO. 007 found no significant differences between two groups with clin-
Does Mobile Insert Contribute to Knee Kinematics ical and radiographic results or prevalence of polyethylene wear
after Total Knee Arthroplasty? osteolysis at minimum 10 years follow-up.
Kenrin Shi, MD, Osaka, Japan (n) PAPER NO. 009
Kenji Hayashida, MD, Osaka, Japan (n) Wear in Crosslinked Mobile-Bearing Knee
Hideo Hashimoto, MD, PhD (n)
Susumu Saito, MD, Toyonaka, Japan (n) Arthroplasty Components Under Aggressive
Abstract: Femoral component rollback and tibial internal rota- Conditions
tion were evaluated under fluoroscopy to verify the contribution Juan C Hermida, MD, La Jolla, CA (a – DePuy)
of mobile insert to knee kinematics after total knee arthroplasty Nick Steklov, BS, La Jolla, CA (a – DePuy)
(TKA) either in patients with osteoarthritis (OA) or rheumatoid Kace A Ezzet, MD, La Jolla, CA (a – DePuy)
arthritis (RA). Fifty-six TKAs of 45 patients with NexGen Legacy Clifford W Colwell Jr, MD, La Jolla, CA (a – DePuy)
Posterior Stabilezed Flex (Zimmer) were studied at least one year
Darryl D D’Lima, MD, La Jolla, CA (a – DePuy)
after surgery. Mobile insert was utilized in 17 OA knees and 13
RA knees, while fixed in 17 OA and 9 RA. Sequential lateral radi- Abstract: Knee component malalignment and increased patient
ographs of the knees during passive flexion under fluoroscopy activity, especially in younger patients, can increase the risk for
were evaluated for femoral component rollback and tibial failure in part due to increased wear rate. Crosslinking polyeth-
internal rotation. Maximal flexion angle was also measured in ylene has not gained widespread acceptance in knee arthro-
each knee and data were analyzed regarding the comparison plasty. Mobile bearings can reduce wear rates under aggressive
between mobile and fixed as well as between OA and RA. conditions because the shear generated during rotation is
Femoral component rollback was observed in deep flexion over reduced at the upper articulating surface, which has to be
90 degrees in all subgroups, but no significant differences were balanced against the potential for increased wear at the lower
noted regarding disease and insert types. More than 5 degrees of bearing surface. We tested the hypothesis that crosslinking poly-
tibial internal rotation was also observed in deep flexion over 90 ethylene mobile bearings would reduce wear under aggressive
conditions. Rotating platform mobile-bearing inserts were tested

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
427
PPSE 07:Layout 1 1/12/07 1:41 PM Page 428

in an AMTI knee wear simulator under aggressive conditions. been demonstrated in prospective comparison. We conducted a
The varus malalignment condition simulated the increased randomized prospective clinical trial to compare a mobile-
medial load generated by tibial varus greater than 3°. For the bearing and fixed-bearing cruciate-substituting TKA of the same
increased rotation condition, tibial rotation range was increased design. Patients 60 years of age or older were prospectively
from 7° (ISO recommendation) to 14°. Mobile bearings in the randomized to receive either a cruciate-substituting Depuy
crosslinked group were machined from polyethylene crosslinked Sigma® rotating platform (RP) design or fixed-bearing design
using 5 Mrads and sterilized using gas plasma. Mobile bearings with an all-polyethylene tibia (APT). The monoblock APT was
in the control group were sterilized in vacuum foil to a dose of selected to test a long-term hypothesis regarding nonarticular
40 kGy as per current industry standard. Wear was measured by surface wear in TKA. There were no significant demographic
the gravimetric method. Wear rates for control mobile-bearing differences between the groups (mean age=72.7; mean ASA
inserts were 7.49 (±1.35) mg per million cycles under aggressive score=3; mean BMI= 31). Routine clinical and radiographic
conditions. Crosslinking the bearings reduced wear rates by 50% followup included Knee Society scores (KSS), WOMAC, and SF-
to 3.84 (±0.33) mg per million cycles, (p< 0.05). Active patients 36 outcome measures. A total of 222 TKAs in 209 patients (102
are at risk for polyethylene wear due to repeated exposure to AP/120 RP) had at least two-year (mean 32 mo) followup. There
aggressive kinematic conditions. Crosslinking polyethylene led was no significant difference in preoperative ROM, KSS clinical
to less wear in rotating platform bearings in our knee wear simu- or functional scores, WOMAC scores, or radiographic measures
lator of varus malalignment and increased rotation. Crosslinked between the groups. Although there was significant improve-
polyethylene is a promising material that deserves further study ment for both groups, there was no significant difference (p<
such as fatigue testing of mobile bearing stems and posterior .05) in mean postoperative ROM ( 110° AP/108° RP), mean KSS
stabilized posts. clinical scores (91 AP/ 89 RP), or mean KSS pain scores (46
AP/44 RP) at this followup point. There were seven revisions;
PAPER NO. 010 five for infection (3 AP/2 RP), one for fracture (AP), and one for
Randomized Fixed Versus Mobile Bearing Clinical instability (RP). No patient was lost to followup. Both designs
functioned equivalently at early followup. There was no signifi-
Outcome Study Using a Single Knee Prosthesis cant clinical advantage of the RP design over an APT design in
System this patient group, and the RP design was more costly ($1875).
Steven M Teeny, MD, Lakewood, WA (a, b, e – DePuy) Continued use of both designs in this population is justified
Frank V Alusio, MD (a – DePuy) based on these results.
Eugene Paul Schoch III, MD, Austin, TX (a – DePuy)
PAPER NO. 012
Jeffrey A Murphy, MS, Warsaw, IN (e – DePuy)
Tammy L O’Dell, CCRC, Warsaw, IN (e – DePuy) Does the Mobile Bearing Implant Lead to Better
Abstract: The clinical experience of fixed-bearing (FB) implant Clinical Outcome if Compared to Fixed Bearing?
systems is well recognized while mobile bearing (MB) rotating Samih Tarabichi, MD, Dubai, United Arab Emirates
platform knees have seen less use. The purpose of this study was (b – Zimmer)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

to compare posterior cruciate sacrificing FB to MB knees using Marwan Hawari, MD (b – Zimmer)

clinical outcomes. Between April 2001 and October 2002, 122
Abstract: It is still not clear if mobile bearing has definite advan-
(106 patients) total knee arthroplasty’s were performed at three
tage over the fixed bearing implant. The purpose of this study is
sites using either a FB (58) or MB rotating paltform (64) P.F.C.
to compare result of mobile bearing with the fixed bearing in
Sigma prosthesis. Average age was 65.3 years (range 39 to 80
large series of patient who had the same femoral component.
years); 65 percent (69/106) of the subjects were female; 96.7
523 cases of a mobile bearing were compared to 426 cases of
percent were diagnosed with osteoarthritis. Two patients (2
fixed bearing performed between January 2001 and May 2004.
knees) in the MB group died of causes not related to the implant.
Initially the surgeon used only mobile bearing until Feb 2004
Clincally important shifts were detectible with 80 percent power.
when he switched to fixed bearing implant. The surgeon used
Minimum 2-year follow-up was available for 95 knees providing
the same LPS (posterior stabilizer) femoral component in both
80 percent follow-up compliance. Average follow-up of the
groups and the same pre-operative protocols were implemented
minimum 2-year group was 3.2 years with a range of 2 to 5 years.
for both groups. Average ranges of motion and knee scores were
There were no statistical differences in demographic (age, BMI,
similar in both groups .Complications were the same except for
gender,diagnosis), surgical time, clinical quality of life (mental
knee dislocation. We had five knee dislocations in the mobile
and physical SF-12), or complications at last follow-up, or
bearing group none in the fixed group. Three cases required revi-
change from preoperative follow-up to last postoperative follow-
sion with thicker spacer and two had close reduction. The dislo-
up. Early results suggest no significant differences between FB
cation happened in patients who had severe knee deformity
and MB implants using clinical, quality of life, and complication
preoperatively. The knee score and range of motion failed to
outcomes. Longer-term follow-up is warranted to determine
show any advantage of mobile bearing implant. Knee disloca-
whether the laboratory polyethylene wear differences between
tion is a major concern especially when patient has gross knee
FB and MB implant systems are realized clinically.
deformity. The knee dislocation happened because of laxity of
the collateral ligament as a result of the soft tissue release rather
PAPER NO. 011
than flexion extension gap mismatch, and the revised cases only
Randomized Clinical Trial of Mobile-Bearing and required thicker spacer. We believe that surgeons should avoid
Fixed-Bearing All-Poly TKA Designs using mobile bearing in selected cases.
Terence J Gioe, MD, Saint Paul, MN (a – Depuy, Inc.)
Neil R Johnson, MD, Edina, MN (n)
Abstract: Mobile-bearing total knee arthroplasty proponents cite
potential advantages of diminished backside wear and improved
range of motion and/or function, but these advantages have not

428 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 429

PAPER NO. 013 clinical and radiographic results of fixed-and mobile-bearing

A Comparison of Range of Motion and Outcome in TKA after 13.2 years follow-up, were comparable. However, there
was no evidence superiority of the former TKA over latter TKA.
Fixed and Mobile Knee Designs
Peter John James, FRCS, Nottingham, United Kingdom PAPER NO. 015
(a, e – DePuy) A Prospective RCT using RSA of a Trabecular Metal
Mark J Blyth, FRCS, Kirklee, United Kingdom (a – DePuy) Tibial Monoblock TKA Component - 1 Year Results
Pauline May, Cape Town, South Africa (a – DePuy)
Michael Dunbar, MD, PhD, Halifax, Canada
Wendy Gerrard Tarpey, BA, Nottignham, United Kingdom
(a – Zimmer, Depuy, Stryker, Wright Medical, e – Stryker)
(a – DePuy)
David Wilson, BEng (n)
Ian G Stother, MD, Glasgow, United Kingdom (a – DePuy)
Allan Hennigar, Halifax, Canada (n)
Abstract: This study aims to establish whether or not mobile
John David Amirault, MD, Halifax, Canada (n)
bearing TKR delivers any benefits of improved function and
range of motion when compared to its fixed bearing equivalent. Gerald Peter Reardon, MD, Halifax, Canada (n)
A total of 351 patients undergoing a PS PFC Sigma TKR were Michael Gross, MD, Halifax, Canada (e – Wright Medical)
randomly allocated to receive either a Mobile Bearing (174 Abstract: RSA was used to compare micromotion at the tibial
knees) or a Fixed Bearing (177 knees) tibial tray. All knees were component/bone interface between the uncemented Nexgen
scored using standard tools (Oxford, AKSS) preoperatively and TM monoblock and cemented Nexgen cobalt chrome modular
at one year postoperatively by independent nurse specialist knee prostheses. Sixty-seven patients with primary OA of the
observers. The range of motion increased from a mean of 96 deg. knee were randomized to the TM monoblock (n=34; 20 female;
(pre-op) to a mean of 108 deg. at 1 year post-op for both the mean age=66 years; mean BMI=32) or cobalt chrome modular
fixed and mobile bearing (p=0.972). The change in Oxford Knee (n=33; 19 female; mean age=65 years; mean BMI=33) PS knees.
Score from pre-operation to one year post operation was 18.2 Surgical technique and post-operative protocol were standard-
with the mobile bearing and 19.0 with the fixed bearing ized. SF-36, WOMAC, PCS, KSCRS were administered pre-oper-
(p0.489) and was not significant. Overall the American Knee atively and at 6, 12 and 24 months post-operatively and BMI
Society knee score and function scores at 1 year were not signif- was recorded. Within 4 days and 6, 12 and 24 months post-
icantly altered by the use of a mobile tibial bearing, though the operatively patients underwent uni-planar RSA exams. The TM
change in knee score was greater for the fixed bearing over the group had greater initial migration but appeared stabilized at 1
mobile bearing tray (49.4 vs 46.5: p=0.03). There was no meas- year. There were 2 TM subgroups based on migration at 6
urable improvement in range of motion at 1 year post-op with a months: one with mean values of 2.1 mm and the other with
mobile bearing design. The 1 year Oxford knee score and AKSS mean values (0.4 mm) comparable to the modular group (0.6
knee score and function scores were similar for both designs. The mm). There was no significant migration between 6 and 12
Knee score change from pre-op to 1 year was slightly higher for months for both implants indicating good fixation to the prox-
fixed bearing trays with no clear explanation. It is likely that imal tibia. There were no differences between groups in the
outcome measures, age and BMI. There was no difference in

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

most potential advantages of a mobile bearing design will mani-
fest themselves in longevity rather than function. micromotion between groups at 1 year post-op and all knees
appeared well fixed to the proximal tibia by 6 months postop.
PAPER NO. 014 The TM monoblock was prone to greater initial migration,
Long-Term Results of Fixed-Bearing and Mobile- however, this does not appear to compromise long-term fixa-
tion. Long-term survivorship of the TM tibial component should
Bearing Total Knee Arthroplasties be equal to or better than a cemented cobalt chrome tray.
Young-Hoo Kim, MD, Seoul, Republic of Korea (n)
Jun Shik Kim, MD, Seoul, Republic of Korea (n) PAPER NO. 076
Dae-Ya Kim, MD, Seoul, Republic of Korea (n) Effect of Each Step of the Medial Soft Tissue
Abstract: The purpose of the present study was to compare the Releases in Medial Osteoarthritic Knees During TKA
long-term results associated with fixed-bearing and mobile-
Ryuji Nagamine, MD, Fukuoka, Japan (n)
bearing total knee arthroplasties in the same patient who had
bilateral simultaneous total knee replacements. One hundred Keiichi Kondo, MD, Kitakyushu City, Japan (n)
and forty-six patients (mean age, 69.8 years) received an Motoki Sonahata, MD (n)
anatomic modular knee (AMK) fixed-bearing knee prosthesis in Abstract: The purpose of this study was to assess the effect of
one knee and a low contact stress (LCS) mobile-bearing total each step of medial soft tissue releases on the joint gap angle and
knee prosthesis in the contralateral knee. Eight patients were distance during PS TKA. 131 varus medial osteoarthritic knees
men, and 138 patients were women. At a mean of 13.2 years were assessed. Before and after each release of the medial soft
(range, 11 to 14.5 years) postoperatively, the patients were tissue release, 30 inch-pounds were applied to distract the
assessed clinically and radiographically with use of the knee femorotibial joint using a tensor/balancer device. Joint gap angle
rating system of the KS and HSS. Polyethylene wear and osteol- and distance were assessed both in full extension and at 90o
ysis were determined. The mean KS knee score at the final flexion. The order of the releases was deep MCL, superficial
follow-up was 92 points in the AMK group and 90 points in the MCL, pes anserinus and semi-membranosus. Superficial MCL
LCS group. The mean functional score was 81 points in the AMK was released selectively. The release was done up to deep MCL in
group and 83 points in the LCS. In the AMK group, 2 knees (1%) 40 cases (30.5%), up to superficial MCL in 91 cases (69.5%), up
were revised for wear of tibial bearing and 2 knees (1%) were to pes anserinus in 26 cases (19.8%) and up to semimembra-
revised for osteolysis, or loosening. In the LCS group, 3 knees nosus in 8 cases (6.1%). The effect of all releases was 2.1o ± 2.1o
(2%) were revised for wear of medial tibial bearing and 1 knee (mean ± SD) in extension and 3.4o ± 3.5o in flexion, and was
was (0.7%) was revised for medial tibial bearing dislocation. The 1.2 ± 1.3 mm and 2.5 ± 2.5 mm, respectively. Release effect of
anterior fiber of superficial MCL was 1.2o ± 1.0o in extension

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
429
PPSE 07:Layout 1 1/12/07 1:41 PM Page 430

and 2.3o ± 2.3o in flexion. Effect of posterior fiber was 1.7o ± points.Six revised knees failed: two by loosening, one by infec-
1.6o and 1.5o ± 1.8o, respectively. Effect of pes anserinus was tion, one by fracture, and two by component “spin-out.”None of
1.8o ±1.3o and 2.8o ± 2.5o. The release effect was larger in the knees revised for infection have failed. Histology obtained
flexion except posterior fiber. According to the results, the degree from failed knees has shown viable bone graft. Although the
of the each step can be predicted before the release. Femoral failure rate was high [over 10%], only two [4%] knees failed by
component size should be larger because the release effect is loosening and all knees were selected for having extensive bone
larger in flexion in PS TKA. loss. Thus, this experience suggests that failed knees, even with
significant bone loss and infection can be reconstructed, lost
PAPER NO. 077 bone reconstituted and a durable construct obtained using
Does Traditional Joint Balancing Work with an MIS impacted morcelised allograft bone.
Incision? PAPER NO. 079
Daniel T Le, BA, Houston, TX (n) Influence of Medullary Canal Diameter in Implant
Michael A Conditt, PhD, Houston, TX (a – Zimmer)
Nikhil Kulkarni, MS, Houston, TX (a – Zimmer)
Positioning
Sabir Ismaily, BS, Houston, TX (a – Zimmer) Suresh Thomas, MRCS, Tyne and Wear, United Kingdom
James M Saucedo, BA (n) (b – Smith and Nephew)
Philip C Noble, PhD, Houston, TX (a – Zimmer) Jay Arora, MRCS (n)
Gangbing Song, PhD (n) Derek J Kramer, MD, Morpeth, United Kingdom
Liang Ren, MS (n) (b – Smith and Nephew)
David Weiner, MD (n) Abstract: This study was done to assess the influence of the
medullary canal diameter on the tibial component positioning
Abstract: In TKA, joint balancing attempts to place both collat-
in total knee replacements done using intramedullary alignment
eral ligaments under equal load during distraction of the cut
guide and to see if modular intramedullary guides would lead to
bony surfaces. With smaller incisions, distraction loads may be
better tibial implant positioning. We analysed 60 consecutive
resisted by other structures, including the retained joint capsule.
total knee replacements where intramedullary alignment guide
The purpose of this study was to examine how an MIS approach
were used for tibial component positioning. All the total knee
affects the strain in both the lateral and medial collateral liga-
replacements in this study were done using the Profix system
ment during joint balancing. Five surgeons implanted a poste-
where a standard 8 mm intramedullary alignment guide is used
rior-stabilized TKA in 5 pairs of fresh cadavers. On one side, a
without taking into account the diameter of the medullary canal.
standard incision was used as well as standard instrumentation.
Position of the tibial component was measured using the
On the other side, an MIS incision with a 10cm subvastus
American knee society scoring and was correlated to the tibial
capsular incision was used with an MIS instrument set.
medullary canal diameter using non parametric correlation
Following complete preparation, each joint was distracted in 0
analysis (Spearman’s correlation coefficients). The analysis
and 90 degrees of flexion with a hydraulic knee tensometer
showed that there was no such relationship between the
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

which applied 50N to the medial and lateral compartment inde-

medullary canal diameter of the tibia and the component posi-
pendently. The strains in both the medial and lateral collateral
tioning. There was no statistically significant correlation between
ligaments were measured with displacement transducers. In 90
intramedullary diameter and antero- posterior positioning .
degrees of flexion, a constant distraction force generated 57%
There was no statistically significant correlation between
(medial) and 80% (lateral) less strain in the collateral ligaments
intramedullary diameter and lateral view positioning . We
with an MIS exposure compared to a standard subvastus expo-
conclude that medullary canal diameter of the tibia does not
sure. Conversely, joint distraction in extension led to a 22%
influence the position of the tibial component when using an
reduction in strain in the lateral collateral ligament, and a 195%
intramedullary alignment guide and there is no requirement to
increase in strain in the medial collateral ligament. Applying a
use modular alignment guides to suit the medullary canal so as
distraction force to the medial and lateral compartments during
to achieve a better implant position.
joint balancing results in strains in the corresponding ligaments
that are significantly affected by the type of exposure. Preserving
PAPER NO. 080
the joint capsule and the attachment of the extensor mechanism
to the patella effectively shunts the distraction load away from Constrained Condylar Knee without Stem Extensions
the collaterals. New techniques are required to effectively for Difficult Primary Total Knee Arthroplasty
balance the joint during MIS procedures. John Anderson, MD, New York, NY (n)
PAPER NO. 078 Andrea Baldini, MD, Prato, Italy (n)
James H MacDonald, MD, Annapolis, MD (n)
Revision Total Knee Arthroplasty with Impaction Paul M Pellicci, MD, New York, NY (n)
Bone Grafting Thomas P Sculco, MD, New York, NY (n)
Gary Worthington Bradley, MD, Santa Barbara, CA (n) Abstract: In the setting of a complex primary total knee arthro-
Abstract: This paper presents a fifteen year experience of one plasty (TKA), the surgical management of severe deformity can
surgeon using morcelized impacted allograft bone to revise 48 be challenging. The inherent stability of a constrained TKA is due
failed knee arthroplasties. At least90cc impacted bone was used to a post in the tibial tray that fits intimately between the femoral
in all knees; except for two knees,standard monoblock revision component condyles. Most authors have advocated the use of
components [DePuy LCS] and no augmentswere used. Nine intra-medullary stems with constrained components for both
knees were revised for infection. All patients were followed revision and complex primary surgery to allow load-sharing over
prospectively; KneeSociety Knee Scores were obtained.Average the diaphyseal portion of the tibia and femur. We believe that by
follow-up is over six years. According to KSKS all patients even- using a non modular constrained TKA without stem extensions,
tually benefitted; the average improvement was over 85 the problems of diaphyseal reaming, excess costs and diffiuclties

430 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 431

with revision may be avoided. We studied 248 non modular has the potential to provide growth factors that may be
constrained condylar total knee arthroplasties consecutively conducive to osteointegration at the bone-implant interface. Our
implanted without the use of diaphyseal stem extensions in 180 study analyzed the influence of PRP on bone ingrowth upon a
patients at 2-6 year follow-up. All patients were examined in the beaded metal implant in distal femurs of twenty-two rabbits.
office and x-rayed. Preoperative deformity was severe (82% Rabbit limbs were randomly assigned to receive an implant plus
Ahlbäck grade 4-5). We reviewed 192 knees (148 patients) at PRP or plain implant on the contralateral limb. Half of the spec-
follow-up of 47 months (range, 24-72 months). Knee Society imens were randomly assigned to a two week group (n equals
score improved from 36 to 89 points, and function score 20) or a five week group (n equals 20). Histological and histo-
improved from 42 to 76 points. Failure rate was 2.5% (2 infec- morphometric comparison between control, implant alone, and
tions; one aseptic loosening; one supracondylar femoral frac- PRP group, implant plus PRP, at two and five weeks was
ture; one tibial post fracture). Six knees (3%) had performed. In both the two and five week comparisons, there
patello-femoral complications. Nonprogressive radiolucent lines was no statistical difference (p great than 0.05) in bone ingrowth
were present in 16% of cases. Use of a non-modular constrained between the control and PRP groups despite a slight increase in
condylar knee for primary severely damaged knees demon- trabecular bone growth in PRP groups. Both control and PRP
strated reliable mid-term results with a low complication rate groups demonstrated intramembranous ossification at two
and questions the routine use of intra-medullary stem exten- weeks and five weeks. Our study suggests that PRP is not a major
sions in all such cases. contributing factor to bone ingrowth at the bone-implant inter-
face. Several previous studies have analyzed PRP and have
PAPER NO. 081 concluded similar results; however, our study is unique in that it
A Functional Assessment of Effect of Posterior analyzed the effect of PRP in combination with a metal implant
on long bones.
Slope of the Tibia in Total Knee Replacement
Nitish Gogi, MBBS MRCS (n) PAPER NO. 083
Anthony Michael Perera, MBChB, Birmingham, Use of Structural Allograft for Major Bone Defects
United Kingdom (n)
During TKA
Binod Singh, MD, Wigan Lancashire, United Kingdom (n)
Ryan D Bauman, MD, Rochester, MN (n)
Abstract: There is an increasing demand for a high range of
flexion following TKR particularly in Asian patients. Although David G Lewallen, MD, Rochester, MN
range of flexion is multi-factorial the posterior slope of the tibial (a, b, c – Zimmer, d – DePuy)
component is an important factor.Studies have shown that there Arlen D Hanssen, MD, Rochester, MN (n)
are significant racial differences in the posterior slope, nonethe- Abstract: Management of large boney defects in TKA usually
less most systems target 3-7 o of slope. The purpose of this study involves modular implants with metal wedges or augments,
was to assess the alteration in the posterior slope and its effect structural allograft, or megaprostheses. The most difficult lesions
on knee scores and flexion. We have conducted a controlled to treat are the larger ones ( AORI Type II and III), where meta-
study of 109 Asian and Caucasian patients. All data has been physeal bone is damaged or absent. In the present study, the

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

collected prospectively and includes personal data, radiological outcome of the treatment of AORI Type II and III lesions with
assessment, knee scores and range of movement. Minimum structural allograft during TKA was examined at a minimum five
follow-up was two years. Both sets had similar arthropathy at the year follow up. Between 1/1/85 and 1/1/01, the Mayo Clinic
time of surgery. Posterior slope in Caucasian patients averaged Total Joint Registry revealed ninety-nine consecutive knees in
3.9 o pre-TKR and 4.55 o post-TKR. In Asian patients the average ninety four patients who underwent total knee arthroplasty with
slope was 10o pre-TKR and 4.45o post-TKR. There was better structural bone grafting for non-oncologic reasons. When
improvement in the knee scores and range of movements in primary arthroplasties and procedures using only autograft were
Caucasians than in Asian patients. The steeper posterior slope in eliminated, seventy-nine knees in seventy-four patients requiring
Asian patients needs to be considered when planning a TKR. revision total knee arthroplasty with structural allograft
This affects the outcome and range of movement. remained. These records were retrospectively reviewed using
chart review, x-ray records, patient surveys and correspondence
PAPER NO. 082 to determine outcomes. Sixteen failures (20.3%) occurred in the
The Influence of a Platelet Concentrate on study group requiring revision. Nine failures were secondary to
allograft failure, three secondary to failure of the non-allograft
Prosthetic Bone Ingrowth in a Rabbit Model component, and four secondary to infection. Fourteen compli-
Christopher D Chaput, MD, Temple, TX cations occurred in fourteen patients. They were ligamentous
(a – DePuy Spine, Cervitech) laxity/instability (2), flexion contracture (2), patellar fx (2),
Kushal V Patel, BA, Friendswood, TX (n) saphenous nerve hypersensitivity (1), symptomatic hardware
George W Brindley, MD, Lubbock, TX (1), pulmonary embolus (1), intra-operative fracture (1),
(a – DePuy Spine, Cervitech) chronic infection (1), soft tissue swelling requiring skin grafting
Marcus A Roux, MD, Waxahachie, TX (n) (1), and soft-tissue defect requiring muscle flap (2). Survivorship
analysis revealed revision free survival at five years of 80.7%
Nianbin Hu, MD, Baltimore, MD (n)
(95% CI 71.7-90.8) and at ten years of 75.9% (95% CI 65.6-
Anton E Dmitriev, BS, Towson, MD (n) 87.8). Our study results support the viability of selective struc-
Bryan W Cunningham, MSc, Baltimore, MD tural allograft use for large bone defects encountered during
(a – DePuy Spine, Cervitech) TKA. However, the rate of complications, reoperations, graft fail-
Abstract: Recent studies have shown that an increase in bone ures and resorption, suggests that efforts to improve results or
ingrowth by addition of osteogenic growth factors can reduce develop more durable alternative methods are warranted.
micro and gross implant motion and contribute to joint implant
stability through osteointegration. Platelet-rich plasma (PRP)

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
431
PPSE 07:Layout 1 1/12/07 1:41 PM Page 432

PAPER NO. 084 recorded. Independent-samples t test were used to compare

A Prospective Double-Blind RCT of Patellar group means (statistically significant: p-values <0.05).
Immediately after surgery, there were less pain, higher satisfac-
Resurfacing in TKA: A Minimum 10-year Follow-up tion and lower morphine usage among patients with PFNB
Study regardless of ropivacaine dosage. At 2 years, there were no signif-
Robert L Barrack, MD, Saint Louis, MO (n) icant differences in OKQ, KSCRS, maximal degrees of knee
Robert Stephen Burnett, MD FRCSC, Saint Louis, MO (n) flexion and extension among groups. Despite immediate post-
operative benefits, PFNB among TKA patients does not affect
Julienne Boone, MD, Saint Louis, MO (n)
functional outcomes at 2-years.
Seth Rosenzweig, MD, Birmingham, AL (n)
Abstract: Patella resurfacing in TKA remains controversial. This PAPER NO. 086
study compares long-term clinical outcomes in TKA performed
with the patella resurfaced(R) or nonresurfaced(NR). Eighty-six
A Multimodal Pain Protocol and Local Periarticular
patients (118 knees-60NR/58R) underwent primary TKA for knee Injections for TKR: A Prospective, Randomized Study
OA. All patients received the same CR-TKA. Patients were Hari Parvataneni, MD, Reading, MA (n)
randomized to NR/R of the patella. Both patient and examiner Vineet P Shah, DO, Naperville, IL (n)
were blinded at follow-up. Evaluations included the Knee Society Amar S Ranawat, MD, New York, NY
Score, patellofemoral-specific patient questionnaire, patient satis- (e – Stryker Howmedica Osteonics)
faction, anterior knee pain scores, radiographs, and complica-
Joanne Weiskopf, PA, New York, NY (n)
tions/revisions. Forty-seven patients(78 knees) were followed to
a minimum of 10-years(range,120-150 months). There were no Holly Howard, BA (n)
significant differences(p>0.05) between the knees treated with Naida Cole, BA (n)
NR/R in range of motion, KSCRS (Total, Pain, Function scores), Chitranjan S Ranawat, MD, New York, NY
satisfaction, anterior knee pain (presence/severity). In the NR (e – Stryker Howmedica Osteonics, DePuy)
group, Total Knee Scores improved from 93 to 155 points, and in Abstract: Uncontrolled pain is the primary concern of patients
the R group from 88 to 146 points. There was no difference in the undergoing total knee replacement. Reduced pain improves
presence of overall knee pain(R=46%,NR=54%); anterior knee patient satisfaction and functional recovery. The purpose of this
pain occurred even less frequently(17% both NR&R) and with study is to describe a multimodal pain protocol including a
low severity(NR:1.4/10<R:1.7/10). Overall revision rates were novel periarticular injection and to evaluate its effects on pain
9%-R and 12%-NR(p>0.05). Seven patients(7/60=12%) in the control, narcotic consumption, and recovery of function after
NR-group and 2 patients(2/58=3.4%) in the R-group required total knee replacement. An IRB-approved prospective random-
revision for a patellofemoral-related reason(P>0.05). In 32 bilat- ized study was conducted to compare different perioperative
eral patients 63% either preferred the unresurfaced knee or had pain management protocols. Patients were randomized to the
no preference. Ten-year follow-up in TKA patients reveals equiva- PCA plus femoral nerve block (FNB) or the periarticular injec-
lent results for resurfaced and nonresurfaced patellae in TKA with tion group. Sixty patients were enrolled.In addition, all patients
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

regards to ROM, KSCRS, anterior and total knee pain, function, were enrolled in a comprehensive protocol including periopera-
PF symptoms, satisfaction, and overall revision rates. The inci- tive analgesics, anti-inflammatories, patient education, and
dence of anterior knee pain was similar between groups. advanced rehabilitation.In the injection group, a local propri-
Patellofemoral rerevision rates were similar between both groups. etary mixture of five medications with different mechanisms of
action was injected into the periarticular sites.Patients were
PAPER NO. 085 assessed for pain (visual analog scale) and recovery of functional
Perioperative Femoral Nerve Block in Total Knee milestones, (unassisted walking, stair-climbing, straight leg raise,
range of motion), and overall satisfaction at POD # 1, 2, 3, 14,
Arthroplasty: Immediate and 2-Year Outcomes 45 and 90. Average pain scores and overall patient satisfaction
Cheuk Fan Shum, MBBS, Singapore, Singapore (n) were comparable between the knee injection group and the PCA
Ngai-Nung Lo, MD, Singapore, Singapore (b, e – Zimmer) + FNB group. However, the knee injection group demonstrated
Seng-Jin Yeo, MD, Singapore, Singapore (b, e – Depuy) lower narcotic usage and associated side effects. Additionally,
Kuang-Ying Yang, MD, Singapore, Singapore 63% of the patients in the knee injection group were able to
(b, e – Stryker Howmedica) straight leg raise on POD #1 versus 21% in the PCA + FNB group.
Hwei Chi Chong, BSc (n) Periarticular injection with a multimodal protocol was shown to
decrease pain and improve functional recovery compared to
Abstract: Perioperative femoral nerve block (PFNB) among total
conventional pain control modalities.
knee arthroplasty (TKA) patients has proven benefits in the
immediate postoperative period. Current literature has no infor-
mation on 2-year functional outcomes. We studied the imme-
diate and 2-year outcomes of PFNB among TKA patients. Sixty
patients undergoing elective unilateral TKA were randomized
into 3 groups (group 1: patient controlled analgesia (PCA)
morphine only, group 2a: PFNB with 0.15% ropivacaine and
rescue PCA, group 2b: PFNB with 0.2% ropivacaine and rescue
PCA). In the immediate postoperative period, pain score, total
cumulative morphine usage, PFNB-related complications, time
of first ambulation and patient satisfaction were studied. At 2
years, patients were assessed with Oxford Knee Questionnaire
(OKQ) and Knee Society Clinical Rating System (KSCRS).
Maximal degrees of knee flexion and extension were also

432 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 433

PAPER NO. 087 arthroplasty. Despite the less invasive approach we found
Femoral Nerve Block After TKA: The Effect on complications associated with TKR surgery as well as those
unique to unicompartmental arthroplasty.
Physical Rehabilitation And Outcomes
Mark Preston Brodersen, MD, Jacksonville, FL (n) PAPER NO. 089
Martin DeRuyter, MD (n) ◆Lateral Unicompartmental Knee Arthroplasty:
Ray A Greengrass, MD, Durham, NC (n) Influence of Alignment on Wear and Loosening
Barry Harrison, MD (n)
Philippe Hernigou, PhD, Creteil France, France (n)
John Putzke, PhD (n)
Jacques Caton, MD, Lyon, France (n)
Kevin Brueilly, MPT (n)
Xavier Poux, MD, Roissy CDG, France (e – Ceraver Osteal)
Abstract: New techniques have evolved to improve the process of
Abstract: Influence of correction of the deformity has been
total knee arthroplasty. Often many changes in this process are
reported for medial unicompartmental arthroplasty. However
made at once and it is hard to know what the effect of any single
little is known for lateral arthroplasty. This report analyzes the
intervention might be. This retrospective study compares the use
influence of the post-operative deformity on the risk of loos-
of femoral nerve catheters (FNC, 24 patients) with standard IV
ening, recurrence of the deformity and progressive osteoarthritis
(PCA, 26 patients) analgesia following total knee arthroplasty.
in the opposite compartment. Between 1981 and 1995, 123
No other changes in surgical technique (no quad sparing/MIS),
lateral cemented unicompartmental arthroplasties with fixed
drugs (no cox-2, etc.) or devices (CPM) occurred. The same
bearing implants were performed. Alignment was measured
arthroplasty implants were used in each group In comparing the
post-operatively as the hip-knee-ankle (H.K.A.) angle on radi-
two groups (FNC vs. PCA) it could be seen that post op pain
ographs of the whole limb. 101 knees retained the original
control was equal in both groups. The FNC group demonstrated
implants until the patient died or until the most recent follow-
improved knee ROM (p=0.004) at the first post op therapy
up examination, 12 were lost to follow-up and revision was
session and at the fourth session (p=0.0003). At the final therapy
performed in 10 knees. Implants (Guepar Mark 1 for the older
session, the FNC group required less assistance in moving from
and Ceraver for the most recent) were evaluated clinically and
sit to stand (p=0.017) and in gait assistance (p=0.072). Length of
for radiographic changes and limb alignment at the time of their
stay in the FNC group was less (3.6 vs. 4.2 days) using the same
most recent follow-up(range, ten to twenty five years). An over-
discharge criteria for all patients. This study demonstrates the
correction in varus (H.K.A. angle less than 177 degrees) was
effect of a single intervention on post op function. As reports
associated with a risk of degenerative changes in the opposite
appear with multifactoral modalities being used, this study can
compartment (3 revisions among these 12 knees). Severe under-
help us to understand what the effect different post op analgesic
correction in valgus (H.K.A. angle more than 186 degrees) was
regimens alone can have on physical therapy progression and
associated with a risk a loosening of the tibial component in the
clinical outcomes.
long term: ( 6 revisions among 30 knees). The best results were
PAPER NO. 088 obtained in the 91 implants that were implanted in normocor-
rection or moderate valgus with a H.K.A. angle of 177 to 186
High Early Failure Rate of an All-Polyethylene Tibial

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

degrees (one loosening among 91 implants). However the valgus
Component Used in Unicondylar Arthroplasty deformity of these successful implants tended to recur at the
Brian R Hamlin, MD, Morgantown, WV (n) latest follow-up (ten to twenty five years); this change in align-
William A. Jiranek, MD, Richmond, VA (e – Depuy) ment was indicative of polyethylene wear and/or minor subsi-
dence of the tibial component.However,wear of the
Abstract: Unicompartmental designs and techniques have been
polyethylene of the lateral unicompartmental knee arthroplas-
developed so to preserve boneand minimize soft tissue trauma.
ties was less than wear observed in medial arthroplasties of the
These modern designs and quadriceps sparing techniques have
same design. Overcorrection increased the risk of disease
been introduced with little support reported in the peer reviewed
progression in the contralateral compartment. Severe undercor-
literature. From October 2002 through May 2004, 64 consecu-
rection increased the risk of loosening of the tibial component.
tive Depuy Preservation unicompartmental arthroplasties (UKA)
were performed in 56 patients. Two patients died of unrelated PAPER NO. 090
consequences leaving 62 UKAs for review (54 medial, 8 lateral).
All procedures were performed through a quadriceps sparing Lateral Unicompartmental Knee Arthroplasty-
approach. All components were cemented including an all-poly- Results in Primary and Posttraumatic Arthritis
ethylene tibial component. Clinical and radiographic data were Alexander P Sah, MD, Boston, MA (n)
analyzed using SAS software At an average follow up of 2.5 years Richard D Scott, MD, Boston, MA (c – DePuy)
(range 2 to 3.6), six (11%) of the medial tibial components have
Abstract: Unicompartmental knee arthroplasty of the medial
subsided. Of these, four have moderate to severe pain, one has
compartment is durable with excellent clinical outcomes at
required conversion to a total knee arthroplasty (TKA), and
long-term follow-up. Arthritis isolated to the lateral compart-
another has stabilized. An additional two patientshave pain
ment is much less common and, subsequently, clinical
throughout the knee (one requiring conversion to TKA) leaving
outcomes are less frequently reported. The purpose of this study
a total of 55 UKAs (89%) functioning well at early follow-up.
was to determine mid-term clinical results of lateral UKA
Additional complications have included four deep vein throm-
through a medial approach for the treatment of both primary
boses, three cardiac issues, one surgical site infection, one intra-
and posttraumatic arthritis. From 1991 to 2004, 49 consecutive
operative medial femoral condyle fracture, and one re-operation
lateral UKAs were performed in 45 patients by a single surgeon
for loose cement fragments. This study demonstrates a high rate
at our institution. Lateral arthroplasty was performed 38 times
of subsidence of all polyethylene tibial components used in
for primary arthritis and 10 times for arthritis secondary to tibial
unicondylar arthroplasty resulting in pain and failure of the
plateau fracture. Radiographic limb alignment and Knee Society
knee and function scores were determined immediately preop-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
433
PPSE 07:Layout 1 1/12/07 1:41 PM Page 434

eratively and at latest follow-up. Both groups averaged 5.2 years patients who require surgical evacuation of an acute hematoma.
(range, 2-15) follow-up. The preoperative knee scores did not Between 1981 and 2004, 17,790 primary total knee arthroplas-
differ between the two groups. The fracture patients were, ties were performed at our institution. Forty-eight patients (48
however, significantly younger at time of surgery and required knees) returned to the operating room within thirty days of
larger tibial inserts. Postoperative alignment was similar between index arthroplasty for evacuation of a postoperative hematoma.
the two groups. Knee scores were significantly greater for patients The rate of return to surgery within thirty days for evacuation of
with primary arthritis compared to those with posttraumatic postoperative hematoma was 0.27%. For patients undergoing
arthritis. Lateral unicompartmental knee replacement through a postoperative hematoma evacuation, the two year cumulative
medial approach has a similar outcome to medial arthroplasty probabilities of undergoing major subsequent surgery (compo-
when performed for primary arthritis. In the setting of a younger nent resection, muscle flap coverage or amputation) or devel-
patient with a plateau fracture, however, outcomes of lateral oping deep infection were 13.3% (95% confidence interval
unicompartmental replacement are inferior to those for primary 2.7-22.9%) and 9.2% (95% confidence interval 0.2-17.9%),
osteoarthritis. respectively. In contrast, for knees without early hematoma evac-
uation, the two year cumulative probabilities were 0.6% (confi-
PAPER NO. 091 dence interval 0.5-0.7%) and 0.8% (confidence interval
Surgical Treatment of Early Wound Complications 0.6-0.9%), respectively (p <0.0001 for both outcomes). Patients
that return to the operating room within thirty days from the
Following Primary Total Knee Arthroplasty index total knee arthroplasty for evacuation of a postoperative
Daniel D Galat, MD, Rochester, MN (n) hematoma are at significantly increased risk for developing deep
Scott C McGovern, MD, Rochester, MN (n) infection, and/or undergoing further major subsequent surgery
Arlen D Hanssen, MD, Rochester, MN (n) including resection arthroplasty, amputation or muscle flap
Henry D Clarke, MD, Scottsdale, AZ (n) coverage. The data supports efforts to minimize the risk of post-
Abstract: Wound healing problems are a known complication operative hematoma.
after primary total knee arthroplasty (TKA). However, the rate
and sequelae of early wound complications that require surgical PAPER NO. 093
treatment following primary TKA are largely unknown. Between Direct Peroneal Nerve Injury with the Inside-Out
1981 and 2004, 17,790 primary total knee arthroplasties were Lateral Release in Valgus Total Knee Arthroplasty
performed at our institution. Sixty-seven knees were identified as
Matteo Bruzzone, MD, Torino, Italy (n)
having early wound complications, necessitating surgical treat-
ment within thirty days of index arthroplasty. Wound complica- Amar S Ranawat, MD, New York, NY
tions included dehiscence, skin edge necrosis, superficial (e – Stryker Howmedica, DePuy)
infections, delayed healing, or persistent drainage. All cases of Federico Dettoni, MD (n)
deep infection below the fascia were excluded. Surgical treat- Roberto Rossi, MD, Turin, Italy (n)
ment included debridement, skin edge excision, primary closure Abstract: Concern has been expressed over the use of “inside-
or delayed primary closure. The rate of return to surgery within out” lateral release technique to correct valgus deformity in total
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

thirty days for surgical treatment of superficial wound complica- knee arthroplasty for the risk for direct, laceration-type injury of
tions was 0.38%. For knees with early surgical treatment of the common peroneal nerve. The objectives of our study are (1)
wound complications, the two year cumulative probabilities of to define the 3D anatomy of the peroneal nerve using cadaveric
undergoing major subsequent surgery (component resection, dissections, and (2) to identify an anatomic landmark on the cut
muscle flap or amputation) or developing deep infection were tibial surface to help in the mapping of the location of the nerve
9.3% (95% confidence interval 1.9-16.7%) and 8.6% (95% during the lateral soft tissue release. Twenty cadaver knees were
confidence interval 1.1-15.6%), respectively. In contrast, among used for testing. Knee replacement surgery was performed and
knees without early surgical intervention for wound complica- the common peroneal nerve identified in all specimen. The
tions, the two year cumulative probabilities were 0.6% (confi- distance from the postero-lateral corner of the tibia to the closest
dence interval 0.5-0.7%) and 0.8% (confidence interval 0.6 margin of the nerve was measured by three different examiners,
-0.9%), respectively (p <0.001 for both outcomes). Patients as well as the diameters of tibial plateau. The tibial plateau was
requiring early surgical intervention for wound healing prob- also divided clock-like in order to define the position of fibular
lems after primary TKA are at significantly increased risk for head and the trajectory of the nerve. The nerve-to-bone distance
developing further complications including deep infection, was averaged 13.54 mm (range 11.20-18.60 mm) and was
and/or undergoing major subsequent surgery, including resec- strongly correlated with tibial plateau diameters. The danger
tion arthroplasty, amputation or muscle flap coverage. These zones were located on average between 9.25 and 10.36 for the
results emphasize the importance of obtaining primary wound right knee and between 1.26 and 2.42 for the left. This study
healing after TKA. showed that the common peroneal nerve is at risk of direct
lesion during the release of the postero-lateral capsule, not
PAPER NO. 092 during the ‘pie ‘ crusting’ of the iliotibial band: hence, use of
Early Return to Surgery for Postoperative Hematoma electrocautery is recommended during the release of postero-
lateral capsule. Special attention must be taken in patients with
Evacuation after Primary Total Knee Arthroplasty
small diameter of tibial plateau.
Daniel D Galat, MD, Rochester, MN (n)
Scott C McGovern, MD, Rochester, MN (n)
Arlen D Hanssen, MD, Rochester, MN (n)
Henry D Clarke, MD, Scottsdale, AZ (n)
Abstract: Development of a postoperative hematoma is a
reported complication after primary total knee arthroplasty
(TKA). However, little is known about the clinical outcomes in

434 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 435

PAPER NO. 094 revision. 18 surgeons experienced failures. The 1st, 2nd or 3rd
Patellar Complications After Primary Total Knee UKA accounted for 58% of their failures. 77% of failures were
within the first 10 arthroplasties. For this subgroup, cumulative
Arthroplasty: Evaluation of 14,978 Consecutive TKA experience of 10 or more arthroplasties correlated with a 6.9%
Nattapol Tammachote, MD, London, Canada revision rate. Less than 10 had 43.1% revision rate. For 15 arthro-
(a – DePuy, Stryker Howmedica, Zimmer) plasties, the rates were 5.4% and 32.5%, respectively. UKAs are
Cathy D Schleck, BS, Rochester, MN (n) an excellent option for appropriately selected patients. Higher
William Harmsen, MS, Rochester, MN (n) cumulative surgical experience decreased revision rates. For
Daniel J Berry, MD, Rochester, MN surgeons with failures, the first 3 UKAs accounted for 58% of
them. The predominant failure mechanism was tibial aseptic
(a – Stryker Howmedica, Zimmer, a, c – DePuy)
loosening. Attention to tibial implantation technique is advised.
Abstract: To evaluate the long-term risk of patella complications
as a function of time after the primary TKA. 14,978 primary PAPER NO. 096
TKAs with patellar resurfacing were performed in 10,773 patients
at one institution between 1977 and 2003. The patients had a
Resource Consumption in Total Knee Arthroplasty
mean age of 69 years and included 5974 female patients and Revision
4799 male patients. The cumulative risk of patella complication Carlos J Lavernia, MD, Coral Gables, FL (a – Zimmer,
was estimated with the Kaplan-Meier survival method. The Cox- Medtronic, e – Zimmer, Orthosoft, d – Zimmer)
proportional hazards survival method was used to assess risk Victor Hugo Hernandez, Miami, FL (n)
factors for patella complications. 1090 knees had a patellar or
Michele R D’Apuzzo, MD, Miami, FL (n)
extensor mechanism complications. The most common compli-
cations were patellar component loosening (n=191), instability David Lee, PhD, Miami, FL (n)
(n=176), and fracture (n=176). The overall cumulative proba- Abstract: Total knee arthroplasty is the second most common
bility of first patellar complication was 4.7% at 5 years and 8.9% elective orthopedic procedure. 3-10 % of these joints fail each
at 10 years and then rose at a nearly constant rate of approxi- year due to loosening, infection or component failure. Our
mately 1% every year to 22.8% at 25 years. In univariate analyses objective was to study the resource consumption in revision
the relative risk of patellar complication for male patients was TKR. Total hospital charges were available on one hundred (100)
1.6 (95% CI: 1.4,1.8) and among patients 70 years old or more revision TKA cases from a single surgeon database. Charges were
was 0.7 (95% CI: 0.6,0.8). This paper quantities the risk of adjusted to reflect 2005 dollars using the Consumer Price Index.
patellar complications in a very large study group over a long Peri and post-operative complications were recorded. Mann-
time period. The study provides a benchmark against which Whitney and chi-square tests were used to compare charges,
evolving surgical methods and newer implants may be length of stay, and complication rates in revision sub-groups; a
compared. Males and younger patients are at higher risk for p< 0.05 was considered significant. Mean charges for the cohort
patellar complications. The most common complications were were $73,696 ± 3,731.5 S.E. Charges were significantly greater in
patellar loosening, fracture, and instability, which occurred in the revision subgroup which received all new components
approximately equal proportions. $68,911 ± 3,942 S.E. versus those undergoing two ($43,233 ±

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

3,116 S.E) and one component ($37,476 ± 2901 SE) revisions
PAPER NO. 095 (p’s <0.001). Complication rates were greater in the two and all
component-exchange subgroups 11.1% relative to the one
Failure Modalities in 601 Unicompartmental Knee component exchange group (p’s <0.05). Patients undergoing
Arthroplasties revision arthroplasty due to infection had significantly higher
Vivek Mohan, MD, Alexandria, VA (n) charges relative to those undergoing surgery for all other reasons
Monti Khatod, MD, Santa Monica, CA (n) ($109,805 ± 5,869 SE vs. $55,911 ± 2902 SE; p<0.001). They also
Liz Paxton, MA, San Diego, CA (n) had longer hospital stays (16.1 ± 1.6 SE vs. 6.6 ± 0.4; p<0.001),
Stefano Alec Bini, MD, San Francisco, CA (n) and had higher complication rates 21.2% vs. 9%; p< 0.001). Our
data suggest that revision knee arthroplasty is an extremely
Donald C Fithian, MD, El Cajon, CA (n)
resource intensive procedure. Revisions for deep infection are
Robert S. Namba, MD, Irvine, CA (n) one of the highest resource consumption procedures in ortho-
David Weiner, MD (n) pedic surgery.
Abstract: The purpose of this study was to elucidate modalities
of unicompartmental knee arthroplasty failures using a commu-
nity-based total joint registry of 601 UKAs A retrospective review
of prospectively collected clinical and radiographic data was
performed. 26 of the 601 UKAs failed for a cumulative revision
rate of 4.3%. 16 [62%] were revised within 1 year of the index
arthroplasty. Average time to revision was 1.03 yrs. Average age
was 58 yrs with a female predominance [N=17]. 50% of the fail-
ures were younger than 60 yrs. Mean weight was 183 lbs
(BMI=29.2). The principal diagnosis was osteoarthritis in 25
patients and AVN in one. 2 of the 26 were lateral arthroplasties.
Minimal flexion contractures (average 1.4 degs) were seen.
Modalities of failure primarily involved the tibia: 14 with aseptic
loosening (8 isolated, 5 with subsidence, 1 with fracture), subsi-
dence (2) and periprosthetic fracture (1). Other modalities:
arthrofibrosis (1), infection (1), OA other compartments (2)
and axial malalignment (1). 4 patients had unclear etiologies for

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
435
PPSE 07:Layout 1 1/12/07 1:41 PM Page 436

PAPER NO. 097 PAPER NO. 098

VTE Prophylaxis in THA/TKA using Lovenox: Clinically Significant Outcomes from DVT
Results/Surgical Site Complications in 290 Patients Prophylaxis of 6457 Primary Unilateral Knee
Robert Stephen Burnett, MD FRCSC, Saint Louis, MO Replacements
(a – Smith & Nephew) Monti Khatod, MD, Santa Monica, CA (n)
John C Clohisy, MD, Saint Louis, MO Debra O Dee, El Cajon, CA (n)
(a – Zimmer, Wright Medical, Smith & Nephew) Liz Paxton, MA, San Diego, CA (n)
Douglas J McDonald, MD, Saint Louis, MO (n) Robert S. Namba, MD, Irvine, CA (n)
Rick W Wright, MD, Saint Louis, MO (n) Donald C Fithian, MD, El Cajon, CA (n)
Robert A Shively, MD, Saint Louis, MO (n) Abstract: Optimal venous thromboembolic (VTE) prophylaxis in
Stephanie A Givens, RN (a – Smith & Nephew) total knee arthroplasty (TKA) patients remains a challenge.
James A Keeney, MD, San Antonio, TX (n) Clinically significant differences in outcome among TKA patients
Robert L Barrack, MD, Saint Louis, MO were evaluated. 6457 primary unilateral TKA surgeries performed
(a, e – Smith & Nephew) between 2001 and 2005 were identified by the Kaiser Permanente
Abstract: Low molecular weight heparins provide effective VTE Total Joint Registry. Data was abstracted from and validated using
prophylaxis in THA/TKA. Wound problems using these agents the Registry, the hospital administrative database, and state death
have created concerns for surgeons. The purpose of this study is records.Patients received either mechanical prophylaxis alone
to report on the efficacy/complications using Lovenox in (1035), coumadin (2276), low molecular weight heparin
THA/TKA patients, with prospective surgical site monitoring 290 (LMWH) (1754), aspirin (1187), or some other form of chemo-
consecutive THA/TKA patients were prospectively entered into a prophylaxis (205). All patients with chemoprophylaxis were
clinical anticoagulation trial (non-pharmaceutical sponsored). included in the analysis with or without adjunctive mechanical
Exclusion criteria included patients that had a high risk history prophylaxis. Adverse events were defined as deep venous throm-
for VTE(ACCP guidelines). In 234 THA/TKA, a 10-day course of boembolism (DVT), pulmonary embolism (PE), fatal PE, and
Lovenox was used for postoperative VTE prophylaxis. Patients death for any cause. No fatal PE occurred. Rates for DVT compli-
were followed to 6-months. Symptomatic DVT/PE, hospital cations were 0.2% for mechanical only, 0.4% for coumadin,
readmission, H.I.T. return to O.R. for surgical site complications, 0.2% for LMWH, and 0.8% for aspirin. Rates for PE were 0.4%
wound drainage(duration+quality), injection site problems, for mechanical only, 0.5% for coumadin, 0.1% for LMWH, and
satisfaction, and relation of preoperative demographics to 0.3% for aspirin. The rates for mortality were 0.3% for mechan-
complications were analyzed Symptomatic DVT/PE occurred in ical only, 0.4% for coumadin, 0.5% for LMWH, and 0.3% for
9(3.8%) and 3(1.3%-all nonfatal) patients. H.I.T. occurred in aspirin. LMWH had significantly lower DVT (p=0.03) and total
3(1.3%) cases. Surgical site complications included 11(4.7%) VTE rates (p=0.02) than aspirin. LMWH had significantly lower
readmissions, 8(3.4%) return to O.R. for wound I&D, 12(5.1%) PE rates than coumadin (p=0.04). Mortality showed no differ-
prolonged hospitalization(wound drainage), 8(3.4%)injection ence amongst prophylactic groups. This study reflects a commu-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

site complications. Wound drainage occurred for 4-7 days in nity based practice outcome in a large number of patients with a
9.3%, and >7 days(range, 8-27 days) in 9.3%, with >7days heterogeneous VTE prophylactic protocol. There were no fatal
predictive of readmission and wound reoperation (p<0.001). PE’s and no difference in mortality. LMWH had the lowest VTE
There was no significant relationship between reoperation or rates of the major prophylactic choices.
VTE with: age, gender, BMI, primary/revision, or THA/TKA.
Ninety percent of patients were satisfied/very satisfied with the
PAPER NO. 099
outpatient injection therapy. Return to the O.R. for wound In Hospital Complications After Total Joint
complications occurred 3 times more frequently with the use of Arthroplasty
Lovenox than in a previous cohort of 705 patients at our institu-
Luis Pulido, MD, Philadelphia, PA (n)
tion that received warfarin (1.2% local wound complications)
for VTE prophylaxis. The use of a 10-day course of LMWH for
Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
VTE prophylaxis in THA/TKA was associated with wound James J Purtill, MD, Philadelphia, PA (n)
complications previously underreported. Surgical site complica- Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
tions requiring readmission or re-operation should be consid- William J Hozack, MD, Philadelphia, PA (e – Stryker)
ered ‘major’ complications when reporting the results and Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
guidelines of future recommendations and studies of VTE Abstract: Total joint arthroplasty (TJA) is a successful procedure.
prophylaxis in THA/TKA With the demographic tendency towards an elderly society and a
relatively high prevalence of arthritis, the number of joint replace-
ment in the US will increase dramatically in the upcoming years.
The orthopaedic surgeons need to be aware of the various types
of complications in the early hospital setting associated with elec-
tive TJA. This study reviewed prospectively collected data on
systemic and local in hospital complications after 14093 TJA,
which included 8008 hip arthroplasties (6514 primary, 225
conversions and 1269 revisions) and 6085 knee replacements
(5413 primary and 672 revisions). A standardized and detailed
form intended to capture all medical and orthopedic complica-
tions was devised, plus a full-time research fellow was dedicated
to this study. The hospital course of every patient was followed on
a daily basis closely. The circumstances leading to the complica-

436 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 437

tions and the details of the therapeutic intervention for each cells/µl had a PPV of 97.1% and NPV of 90.2%, while a
complication were recorded. In general the incidences of compli- neutrophil percentage >63% yielded a PPV of 91.4% and NPV of
cations were higher following revision and knee surgery 98.4%. When fluid cell count and neutrophil percentage were
compared to primary and hip surgery. There were 26(0.18%) combined using their respective cut-off values, the PPV (100%)
deaths in the cohort that occurred within 10 days after surgery, the and NPV (99.6%) increased dramatically. Synovial fluid leuko-
majority of these cases were after revision surgeries. 373 major cyte count and differential are useful adjuncts to ESR and CRP in
(life threatening) complications occurred in the cohort that the preoperative diagnosis for infection in TKA. This study has
included myocardial infarction (34), tachyarrhythmia (111), asys- identified a cut-off value for leukocyte count and neutrophil
tole (2), stroke (16), pulmonary embolus (144), pulmonary percentage that can be used to diagnose infection in a prosthetic
edema (22), respiratory failure (4), pneumothorax (2), acute joint. They have comparable sensitivity and specificity to the
renal failure (32), small bowel obstruction (2), toxic megacolon gold standard of intraoperative culture. When both the values of
(3) and sepsis(3). There were 25 major local complications, fluid cell count and neutrophil percentage are greater than their
including 18 vascular injuries. Most of complications occurred cut-off values, a definite and accurate diagnosis of infection can
within 4 days of index surgery. There were 1053 minor systemic be made. When both test results are less than their cut-off values,
complications, mostly related to anemia, and 536 minor local then we can safely rule out PPI.
complications in this cohort. Total joint arthroplasty despite its
success can be associated with serious and life threatening PAPER NO. 101
complications. The introduction of MIS surgery and the potential Assessing Joint Infection by Rapid Detection of Live
for very early discharge of patients undergoing arthroplasty needs
to be scrutinized in light of these findings.
Bacteria via Real Time Polymerase Chain Reaction
Patrick Birmingham, MD, Washington, DC (n)
PAPER NO. 100 Jeannine Helm, PhD (n)
The Value of Preop Knee Aspiration Cell Count and Paul A Manner, MD, Seattle, WA (e – Zimmer)
Differential in the Diagnosis of TKA Infection Rocky S Tuan, PhD, Bethesda, MD (n)
Abstract: The accurate and rapid diagnosis of a true septic arthritis
Robert Stephen Burnett, MD, Saint Louis, MO
is imperative. We used real time quantitative reverse transcriptase
(a – Smith & Nephew) polymerase chain reaction (RT qPCR) to detect messenger RNA
Ajay Aggarwal, MD, Columbia, MO (n) (mRNA) in synovial fluid as a way to distinguish live and dead
John C Clohisy, MD, Saint Louis, MO bacteria as an indicator of active infection. Synovial fluid samples
(a – Zimmer, Smith& Nephew, Wright Medical) were obtained from healthy joints with sterile effusions in five
Shane T Fejfar, MD, Wichita, KS (n) patients. These samples were inoculated with Escherichia coli,
Morris Kelly, BA, Saint Louis, MO (n) Staphylococcus aureus, methicillin-resistant Staphylococcus
Robert L Barrack, MD, Saint Louis, MO aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis,
or Propionibacterium acnes grown in broth culture as a simula-
(a, e – Smith & Nephew)
tion of septic arthritis. These samples were then analyzed with

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Abstract: Although there is no absolute diagnostic test for PPI,
real time RT qPCR to detect mRNA. The samples were also
synovial leukocyte counts and neutrophil percentages have been
cultured to demonstrate bacterial activity and viability. All
reported to have high sensitivity and specificity making them
infected samples were identified, without any false negatives,
valuable tests for diagnosis. However, no cut off value for the
down to 30 picograms of mRNA per milliliter, 18x103 culture
latter is agreed upon. This study intends to evaluate to define
forming units (CFU) per milliliter, or 100 bacterial cells per 100
definite cut-off values for preoperative synovial fluid leukocyte
microliters. Infection was also detected in antibiotic-treated
count and PMN percentage that allow physicians to diagnose
samples for up to ten days after treatment, with a detectable
infection in a prosthetic joint We analyzed synovial fluid aspi-
decrease in the amount of mRNA over time, which can be corre-
rated preoperatively from 437 total knee arthroplasties (165
lated to the amount of bacteria being killed. The cultures for these
infected; 272 aseptic) from three different institutions. Using
showed no growth. The process start to finish was approximately
ROC curves, we determined cut-off values with optimal accuracy
5 hours. The evidence suggests that this method can be rapidly
in diagnosis of infection for fluid leukocyte count and PMN
and accurately used to detect septic arthritis both before and after
percentage. The sensitivity, specificity, and predictive values were
the initiation of antibiotics. The ability to detect decreasing levels
calculated for the above cut-off values. The ESR and CRP cut-off
of bacteria in response to a given antibiotic allows the determi-
values of 30 mm/hr and 1 mg/dl respectively are frequently used
nation of the appropriate duration of treatment. This method has
in the literature to distinguish between infected and noninfected
many applications including the timely diagnosis and appro-
total joint arthroplasties. We adopted these values and
priate treatment of periprosthetic infections.
combined them with the above determined cut-off values for
fluid leukocyte count and neutrophil percentage. Multiple PAPER NO. 102
combinations were created in hopes of optimizing the diag-
nostic value of these various tests. The synovial fluid leukocyte Heat Shock Proteins for the Diagnosis of Infected
count was higher in patients with PPI (median, 26.25 x 103 Total Knee Arthroplasty
cell/µl) compared to aseptic joint arthroplasties (median, 0.230 Francisco Chana Rodriguez, MD, Madrid, Spain (n)
x 103 cells/µl)( p<0.0001). Chi-square analysis revealed the fluid Maria C Guisasola Zuleta, MD (n)
WBC count and the neutrophil percentage to be significantly
Javier Vaquero Martin, MD (n)
associated with the diagnosis of infection (p<0.0001). Similarly,
the neutrophil percentage was higher in patients with PPI
Julio De Las Heras, MD (n)
(median, 90%) than in those with noninfected joints (median, Abstract: Adaptative response of multicellular organisms to
22%) (p<0.0001). The cut-off values for optimal accuracy in adverse environmental conditions in an attempt to protect
diagnosis of infection were 3120 cells/µl for fluid leukocyte themselves from lethal microorganisms aggressions, include the
count and 63% for PMN percentage. A fluid cell count >3120 synthesis of a series of defence systems, called heat shock

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
437
PPSE 07:Layout 1 1/12/07 1:41 PM Page 438

proteins (HSPs). The acute phase response levels of a series of PAPER NO. 104
35 patients, with the diagnosis of advanced primary Risk Factors for Stiffness Following Total Knee
gonarthrosis, were determined before and after a total knee
arthroplasty and 10 patients who suffered from late chronic Arthroplasty
total knee arthroplasty infection were studied. A pilot observant James J Purtill, MD, Philadelphia, PA (n)
prospective descriptive study with these serum parameters was David Tarity, BS, Philadelphia, PA (n)
conducted. We used the Mann-Whitney U test or the Fisher test Joshi Ashish, MD, MPH (n)
to compare these variables in non infected primary knee arthro- Craig J Della Valle, MD, Chicago, IL (e – Zimmer)
plasties and infected joints. A significant difference, showing Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
higher values in the infected group of fibrinogen, sedimenta-
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
tion rate, C-reactive protein, IL-6, TNF± and temperature, was
observed. Differences in Leukocyte count, fibrinogen, sedimen- Abstract: Although some predisposing factors have been identi-
tation rate, C-reactive protein, IL-6 and antiHSP70i autoanti- fied, in most cases the exact etiology of stiffness following total
bodies were statistically significant in patients without any knee arthroplasty (TKA) cannot be discerned. Ranges from 1.3%
postoperative complications. Measurements of acute phase to 12% have been documented and may be due in part to a
reactants levels can be used to detect the presence or intensity of varied definition of stiffness. The purpose of the study was to
an inflammatory process. We only observed a discreet higher identify factors that predispose patients to stiffness following
level of HSP70i and the other acute phase response values in TKA. 98 patients (112 knees) were identified who developed
patients with a late chronic total knee arthroplasty infection, stiffness (requiring MUA) and were matched for year of surgery
but the differences with no infected patients was not statistically and surgeon with a control group of 208 knees. The clinical and
significant. These serum parameters can not be used as efficient radiographic records of all patients were examined in detail. The
biomarkers in infected knee arthroplasty. results of all interventions (surgical and non-surgical) for treat-
ment of stiffness were also evaluated. Of the 98 patients
PAPER NO. 103 comprising the case group, MUA was performed once for 93
patients and twice for 5 patients. 14 patients underwent revision
Isolated Polyethylene Exchange for Instability and TKA for stiffness. The etiology of stiffness following TKA in the
Wear in Revision Total Knee Arthroplasty latter group was deemed to be arthrofibrosis (13) and technical
Charles Toulson, MD, New York, NY (n) error (1). There was no statistically significant difference in the
Nathan Maust, MD (n) preoperative range of motion between the two groups. Factors
Hyung Suk Choi, MD (n) predisposing patients to stiffness following TKA were identified
which included young age at TKA, low BMI, high femoral flexion
Marc Wilson Hungerford, MD, Baltimore, MD
angle, increased patellar thickness, and patella baja. Stiffness
(e – Zimmer a – Zimmer) following TKA, though fortunately rare, can be challenging. This
David S Hungerford, MD, Baltimore, MD study has identified some predisposing risk factors for this
(c – Stryker Howmedica) dreaded complication. The findings of this study may provide
Harpal Singh Khanuja, MD, Baltimore, MD (a – Zimmer) better counciling for the patients and may serve to reduce the
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Abstract: Polyethylene wear and instability are common indica- development of stiffness following TKA in some patients.
tions for revision total knee arthroplasty. Isolated tibia insert
exchange is an attractive option for treating patients with these PAPER NO. 105
conditions. The goal of this study is to evaluate the effectiveness The Natural History of Pain in Total Knee
of isolated polyethylene component exchange in patients with
frank wear and instability. From 1990 to 2002, twenty-seven
Arthroplasty: Predictors of Pain at 5 Years after
isolated tibia insert exchange procedures were performed at one Surgery
institution for wear and instability. Patients who had infection, Victoria Anne Brander, MD, Chicago, IL (n)
malposition of any component, loosening, or problems with the Emily Martin, BS (n)
extensor mechanism were excluded for this study. All knees were Steven Gondek, BS (n)
the Porous Coated Anatomic prosthesis (Howmedica, S David Stulberg, MD, Chicago, IL (n)
Rutherford, NJ). They had been in situ for 8.2 years (range, 3.8
Regina Bart, PA-C (n)
to 18.1 years). The duration of follow up after isolated tibia
exchange was 6.4 years (range 1.8 to 12.6 years). There were six Abstract: We previously reported 1 in 8 patients experienced
deaths during this period. Six (22.2%) of twenty-seven patients unexplained pain one year after knee arthroplasty (TKA).
in this series failed and required revision at a mean of 4.8 years Preoperative depression, anxiety and pain were associated with
(range, 0.8 to 8.1 years). Of the eight total knee implants revised worse outcome at one year follow-up. The present study sought
for instability, three (38%) failed and required revision at an to determine the ultimate outcome of these patients. In a 5-year,
average of 62 months (range, 38- 97months). Survivorship prospective, single cohort observational study, 99 TKA (mean
calculated for this group was 69% at 53 months. Three of the age 65.3 years, 68 women) were evaluated preoperatively, and at
nineteen (16.0%) implants revised for wear failed at an average 1,3,6 months, 1 and 5 years following TKA. Predictive variables
of 71 months (range, 8-112months). Survivorships for wear included demographic, clinical (e.g., VAS, Knee Society Score),
related exchange was 81% at 94 months. Isolated tibia insert radiographic and psychometric (Beck Depression Index BDI,
exchange for wear or instability is associated with a high failure Stait Trait Anxiety Inventory STAI) factors. Outcomes were pain,
rate. Multiple factors including patient characteristics, implant BDI and KSS. Pre-operative pain and depression predicted lower
design, alignment, and ligament status, must be considered Knee Society Score at 5 years (p = .0003, .0004) mostly by
prior to limited revision of just the polyethylene component. lowering functional subscores (p=.0004). Heightened pre-oper-
ative pain resulted in slightly increased pain at one and five years
after surgery (p = .002, .1). At 5 years, nearly all the patients with
unexplained pain one year after surgery had resolution of pain

438 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 439

and were satisfied with their surgeries. In summary, preoperative PAPER NO. 287
pain and depression are associated with worse outcome 5 years Association of PFP-10 Test with Commonly Used
after TKA. Assuming good ROM and well-aligned implants,
most patients with pain at one year after surgery can be reassured Measures of Function in Knee Osteoarthritis
that pain ultimately resolves. Depression drives long-term Patients
outcomes and should be addressed. This study also suggests KSS Tina T Garrison, MS, Alexandria, LA
is influenced by psychometric variables and therefore is not (a – Smith & Nephew, Inc.)
solely reflective of implant issues.
Jeffrey L Garrison, MD, Alexandria, LA (n)
PAPER NO. 286 David Farrington Pope, MD, Alexandria, LA (n)
Lee A Marsh, MS (a – Smith & Nephew, Inc.)
Optimal Surgical Timing for Total Knee Arthroplasty
Robert H Wood, PhD (a – Smith & Nephew, Inc.)
in Osteoarthritic Patients Abstract: Some commonly used clinical outcome measures for
Chong Bum Chang, MD, Seongnamsi, Republic of Korea assessment of function in knee osteoarthritis (OA) patients
(a – Seoul National University Bundang Hospital Research include the Western Ontario and MacMaster University Index
Fund) (WOMAC), Knee Society Clinical Rating System (KSCRS), and
Yeon Gwi Kang, MD, Seongnam-Si, Republic of Korea (n) the Short Form 36, (SF-36). Another recently developed func-
Heon Jung, MD (n) tional outcome assessment tool, the Physcial Function
Sang Cheol Seong, MD, Seoul, Republic of Korea (n) Performance 10 (PFP-10) test measures physical function objec-
tively. While the above mentioned measures (WOMAC, KSCRS,
Tae Kyun Kim, MD, Seongnam-si, Republic of Korea
and SF-36) are primarily subjective measures, the PFP-10
(a – Seoul National University Bundang Hospital Research protocol requires the participant to perform a variety of activities
Fund) of daily living in a standardized fashion. The purpose of this
Abstract: Patient selection is one of the factors crucial for investigation was to examine the association of PFP-10 with the
successful TKA. When a physician suggests TKA for patients with commonly used measures of function on OA patients. We
advanced knee ailments, age, current symptoms and functions studied the functional performance of 37 patients with severe
and radiographic severity are considered. Despite documented knee osteoarthritis utilizing the Western Ontario and McMaster
longevity of prostheses, it is a common practice to suggest the Universities Osteoarthritis index (WOMAC), Knee Society
delay of TKA until patients get beyond about the age of 65 and Clinical Rating System (KSCRS), and Short Form Physical
radiographic severity is documented. We sought to determine Function (SF-36v.2) scales, as well as the PFP-10. Pearson corre-
the effects of patient age, preoperative symptoms and functions, lation analysis was utilized to determine the degree of associa-
and radiographic severity on patient satisfaction and clinical tions between the variables. The mean values for the PFP-10 total
outcomes after surgery in patients undergoing TKA. 383 knees of score, WOMAC Total Score, function score of the KSCRS, and SF-
240 osteoarthritic patients with uncomplicated TKA were 36 Physical Composite scores were 38.5±20.9, 56.4±14.4,
enrolled in this study. Prospectively collected demographic data, 39.3±15.3, and 37.1±8.0, respectively. The PFP-10 total scores

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

severity score of preoperative radiographs, preoperative WOMAC and correlated well with the WOMAC Total Score (r=-.476;
and SF-36 scores, and postoperative WOMAC score, SF-36 score p=.003), KSCRS Knee Function Score (r=.605, p=.000), and SF-
and level of patient satisfaction assessed at 1 and 2 year after 36 Physical Composite scores (r=.336, p=.045). The WOMAC
surgery were analyzed using multiple regression analysis and Physical Function Sub-score and the SF-36 Physical Function
multivariate analysis of variance. The significant preoperative sub-scores associated with the total PFP-10 score with r-values of
predictors of worse scores of the postoperative WOMAC scale -.578 (p=.000) and .407 (p=.014), respectively. PFP-10 is associ-
were worse preoperative WOMAC score and older age. The post- ated with WOMAC Total Score, KSCRS Knee Function Score, and
operative physical component summary score of SF-36 was also SF-36 Physical Composite scores. This supports the PFP-10 as a
positively correlated with the preoperative SF-36 scores but had useful tool in measuring function in OA patients objectively.
no association with age. There were significantly better preoper- Continued examination of the PFP-10 and other outcomes
ative WOMAC pain scores (p = 0.021) and physical component measurement tools may provide insight into choice of func-
summary score of SF-36 (p = 0.014) in the highly satisfied tional assessment instruments when working with OA patients.
patient group as compared to the dissatisfied group.
Preoperative radiographic severity had no significant association PAPER NO. 288
with all the clinical outcome scores, and level of patient satisfac- Patient Recall following Hip and Knee Arthroplasty
tion. Our data indicate that the patients with worse function and
quality of life at the time of surgery are more likely to have a Does not Accurately Represent Prospective Data
worse postoperative outcome. We also found that preoperative Timothy S O’Brien, MD, Colorado Springs, CO
radiographic appearance is poor predictor of postoperative (a, b – DePuy)
outcome, suggesting that radiographic severity should not be Terri Busey, BA, Colorado Springs, CO (n)
used as a key indication for timing of TKA. This study suggests Jill Oldewage, BA (n)
that TKA performed too late may reduce the patient’s chance of John J Elias, PhD, Colorado Springs, CO (a, b – DePuy)
an excellent outcome.
Abstract: Patient recall can be used as a substitute to collecting
prospective data, although the accuracy of recollection is ques-
tionable. Prospective outcome data was compared to outcome
data based on recall of pre-operative health status at least ten
months after total knee (50 patients) and total hip (38 patients)
arthroplasty. The general health score from the SF-36 scale, func-
tion scores from the Knee Society scale, the Harris Hip scale and
the WOMAC scale, and pain scores from the WOMAC scale were

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
439
PPSE 07:Layout 1 1/12/07 1:41 PM Page 440

quantified. Nonparametric Wilcoxon signed rank tests were PAPER NO. 290
performed to examine for statistically significant (p < 0.05) Randomised Controlled Trial of All Polyethylene vs.
improvements in the prospective data and the data based on
recall. For individual patients, poor recollection of the pre-oper- Metal Backed Tibial Component: 10-Year Results
ative condition was designated as a recalled score differing from Karen Ann Bettinson, RN, Newcastle upon Tyne,
the pre-operative score by more than 50% of the standard devi- United Kingdom (a – Stryker Howmedica)
ation. For both groups of patients, the improvements in function Ian Maurice Pinder, MD, Newcastle Upon Tyne,
and pain were significant for the prospective data and the United Kingdom (n)
recalled pre-operative data, while the improvement in general David Weir, College Station, TX
health was not significant for the prospective data. The improve-
(a, b – Stryker Howmedica, b – Smith & Nephew)
ment in general health based on recalled data was not significant
for the knee patients but was significant for the hip patients. For Christopher G Moran, MD, FRCS, Nottingham,
both groups of patients, at least one-third of the patients had United Kingdom (n)
poor recollection of the pre-operative condition for each scale. Elizabeth Anne Lingard, MD, Newcastle upon Tyne,
Similar numbers of patients overestimated and underestimated United Kingdom (a – Stryker Howmedica, Smith & Nephew)
the pre-operative condition. For total hip and knee arthroplasty, Abstract: Introduction: This study evaluates the best material and
retrospective recall of pre-operative health produced average design for the tibial component by comparing a metal backed
data similar to pre-operative data, but large deviations were and all polyethylene design. Method: Patients were included if
found for individual patients. they were aged fifty or over, had no history of infection and were
undergoing primary total knee arthroplasty. Patients
PAPER NO. 289 randomised at time of surgery. Patients assessed preoperatively
Polyethylene Sterilization and Wear Related Failures: and at 1, 3, 5, 8 and 10 years. All assessments included clinical
history, physical examination and x-rays. Results: A total of 510
A Study with First and Second Generation TKAs (566 knees) consecutive patients were recruited between August
William L Griffin, MD, Charlotte, NC (a, b, c, e – Depuy) 1993 and January 1997. Mean age 69.4, (range 50 to 93years)
Thomas K Fehring, MD, Charlotte, NC (a, b, c, e – Depuy) and 299 (59%) were female. The primary diagnosis was
Donald L Pomeroy, MD, Louisville, KY (a, b, e – Depuy) osteoarthritis for 458 knees (80.9%) and rheumatoid arthritis
Thomas A Gruen, MS, Wesley Chapel, FL (a, b, e – Depuy) for 108 knees (19.1%). Twenty-six knees revised for infection (9
Jeffrey A Murphy, MS, Warsaw, IN (e – Depuy) knees, 2 metal), instability (5 knees, 2 metal), wear (3 knees, 2
Abstract: The purpose of this study was to compare the rate of metal), stiffness (3 knees, 2 metal), trauma (3 knees, 3 metal), 1
wear-related failure between two large series of total knees using fractured baseplate (all poly), 1 oversized femoral component
identical modular tibial trays and polyethylene inserts sterilized (all poly) and 1 unknown (all poly). Ten-year survivorship (95
by different methods. 1183 PFC Sigma (2nd-generation) knee percent confidence intervals) with revision for any reason as the
prostheses with a 5-year minimum follow-up (mean, 7.0yrs) endpoint was 93.2 percent (88.5, 96.0) for the all polyethylene
were assessed by an independent observer for signs of osteolysis. and 96.5 percent (93.4, 98.2) for the metal backed. Ten-year
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

These results were compared with our previously published survivorship for aseptic failures was 96.5 percent (92.6, 98.3) for
study on wear-related failures in 1,287 first-generation PFC the all polyethylene and 97.3 percent (94.4, 98.7) for the metal
modular total knees followed for a minimum of 5 years (mean, backed. There was no significant difference in survivorship
7.8yrs). In the previous study, the polyethylene inserts were ster- between the two designs (p>0.05). Discussion and Conclusion:
ilized by gamma irradiation in air. The PFC-Sigma design used The long-term results demonstrate excellent survivorship for the
polyethylene sterilized and packaged in an oxygen free environ- metal backed and the all polyethylene designs with no signifi-
ment. Using identical criteria for both study groups, wear-related cant difference between the two.
failure was defined as (1) osteolysis > or = to 100 mm2 or (2)
revision due to osteolysis, polyethylene wear, chronic synovitis, PAPER NO. 291
and/or effusion. With a 5-year minimum follow-up, the second- Polyethylene Wear in Primary PCR TKA: A
generation TKA had a wear-related failure rate of 1.1% (13/1184) Comparison of American and Japanese Cohorts
compared to 8.3% (108/1301) with the first-generation PFC. The
Richard Iorio, MD, Burlington, MA (a – Depuy, Pfizer)
Kaplan-Meier survivorship was 97.0% at 10-years in the current
study compared to 87.7% at 10-years in the previous study. Seneki Kobayashi, MD, Matsumoto, Japan (a – Pfizer)
Patient age was the only variable that statistically correlated with William L Healy, MD, Burlington, MA (a – Depuy, Pfizer)
wear-related failure in the current study, whereas, in the original Aristides Ignacio Cruz, Jr MD, New Haven, CT (n)
PFC study with gamma-in-air polyethylene, shelf age, finishing Michael E Ayers, MD, South Weymouth, MA (n)
method, sheet processor, patient age, and gender were all signif- Abstract: Introduction: Excessive polyethylene wear is recognized
icant. This comparative study demonstrates significant improve- as one of the most important factors affecting the durability of
ment in mid-term TKA survivorship with improved TKA, however, bearing surface wear is a multifactorial problem.
manufacturing of polyethylene implants. This study compares two disparate cohorts (American and
Japanese) for the purpose of identifying risk factors for polyeth-
ylene wear and the impact these factors have on survivorship of
PCR TKA. Methods: 73 primary, PCR TKA were performed on 48
Japanese patients, and 76 on 63 American patients. All patients
were evaluated clinically and radiographically. Age, weight,
height, diagnosis, Knee Society patient category, prosthesis size,
insert thickness, alignment, polyethylene wear, osteolysis, KSKS,
KSFS and radiographic and clinical survivorship were evaluated.
Results: 73 Japanese TKA were followed for a mean of 6.6 years

440 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 441

(range 2.0 to 10.6), three (4.1%) required revision. Average wear tively few thus far. The substantial improvement in scores and
in the failed TKA group was greater (1.9 mm) than in the high rate of patient satisfaction (85%) suggests that TKA should
surviving group (0.6 mm). 76 American TKA were followed for continue to be offered to morbidly obese patients. Techniques that
a mean of 9 years (range 2 to 11.2), two knees (2.6%) required can increase the accuracy of alignment may be especially useful in
revision. Average total wear in the failed TKA group (2.7mm) this group of patients.
was greater than in the surviving group (0.8 mm). There were no
significant differences in post operative KSPC, KSKS, or KSFS. PAPER NO. 294
The Japanese patients were significantly smaller in height and Weight and Activity Changes in Obese Patients
weight than the American patients and required smaller pros-
thesis sizes. The Japanese patients were significantly more female
after Primary Total Knee Arthroplasty
dominated and had a significantly less arc of motion. Anne M Lachiewicz, MPH, Chapel Hill, NC (n)
Conclusion: PCR TKA had similar failure rates in a Japanese Paul F Lachiewicz, MD, Chapel Hill, NC (e – Zimmer)
cohort compared with an American cohort despite a smaller Abstract: Obesity is associated with osteoarthritis of the knee. It
stature patient population. is anticipated that after successful total knee arthroplasty, patient
activity should increase and body weight should decrease. There
PAPER NO. 292 are few prospective data, however, on the effect of primary total
Total Knee Arthroplasty in Hemophilic Arthropathy knee arthroplasty on weight and physical activity of overweight
and obese patients in the United States. We conducted a
Carlos Rodriguez-Merchan, MD, Madrid, Spain (n)
prospective study of changes in patient weight, body mass index
Abstract: In the final stages of hemophilic arthropathy, articular
(BMI), and physical activity over two years in 188 consecutive
pain and functional impairment may require a TKA. The
overweight or obese patients (BMI >= 25 kg/m2). Weight and
purpose of this study is to present our results with TKA in hemo-
BMI were assessed preoperatively and at 1 and 2 years. Physical
philia. Over a 10-year period we have performed 35 TKAs in 30
activity was evaluated using the Lower Extremity Activity Scale
patients with hemophilia (5 bilateral). The average age of
(LEAS), a self-assessment instrument. Multiple linear regression
patients was 31 years (range, 24-42). The average follow-up was
was used to examine the relationship between preoperative LEAS
7.5 years (range: 1-10). Two patients had inhibitors to the defi-
score and weight/BMI at 2 years of follow-up. Weight and BMI
cient coagulation factor. The results were assessed according to
data were available for 152 patients (81%) at 2 years postopera-
the Knee Society scores. There was one infection which required
tively. No significant mean weight change was found (p=0.80),
a two-stage revision arthroplasty with a final good result.
but mean BMI increased by 0.46 kg/m2 (p=0.049). The mean
Another knee had excessive bleeding in a patient with inhibitor.
LEAS score for 92 patients increased significantly from preoper-
It was due to an arterial pseudoaneurysm which required arterial
atively to 2 years (p<0.001). At 2 years, 17% of patients had lost
embolization. Results were excellent in 27 knees (77%), good in
>=5% of body weight, 23% had gained >=5% of weight, and
6 (17%), fair in 2 (6%) and poor in 0 (0%). The survival rate at
60% showed <5% change in weight. Preoperative LEAS score
7.5 years on average taking as end-point removal of components
was not associated with weight (p=0.40) or BMI (p=0.51) at 2
for loosening or infection is 97%. Our results confirm that TKA
years. Thus, 2 years after primary total knee arthroplasty, mean
is a reproducible procedure in hemophilia, even in HIV+ posi-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

patient weight did not change, despite an apparent increase in
tive patients and patients with inhibitors.
activity. This finding has important implications for patient
expectations and preoperative counseling.
PAPER NO. 293
Primary Total Knee Replacement in Morbidly Obese PAPER NO. 295
Patients: A Minimum 5 Year Follow-Up Study Minimum 15 Year Follow-up of the Insall-Burstein-I
Robert J. Krushell, MD, Springfield, MA Total Knee Arthroplasty
(a, b, e – Stryker Orthopaedics) Ayesha Abdeen, MD, New York, NY (n)
Richard J Fingeroth, MD, Springfield, MA Kelly Vince, MD, Los Angeles, CA (n)
(a, e – Stryker Orthopaedics) Abstract: This represents a 15-19 year follow up of one hundred
Abstract: This study reports the results of TKA in morbidly obese metal backed, non-modular Insall-Burstein-I posterior stabilized
(MO) patients with 5 to 14 year follow-up versus a case-controlled knee prostheses implanted in 86 patients from 1986-1989 and
group of non-obese patients. Our research database was used to originally reported at 10-12 years The original cohort (57 female;
identify 39 patients who underwent TKA between 1992 and 1999 43 male) had an average age at surgery of 69.7 years (range: 45-
who were morbidly obese (BMI>40) and a case-controlled non- 89). The primary diagnosis was osteoarthritis in 77 knees,
obese (BMI<30) comparison group. There were two revisions (1 inflammatory arthropathy in 17 and post-traumatic arthritis in
tibial loosening, 1 polyethylene wear) in the MO group and no the remaining 6 knees. Six failures occurred by 10 years (1 aseptic
revisions in the comparison group. Combined knee/function loosening, 1 patella fracture, 2 sepsis and 2 non-specific pain).
score means improved from 61 preoperatively to 136 at final At 15-19 years (mean: 16.2 years) fifty patients (60 knees) had
follow-up for the MO group. In the comparison group, mean died, 18 knees were followed with clinical exam and radi-
scores went from 72 to 158. In the MO group 8 knees had minor ographs, 13 by telephone, 3 knees in 2 patients were lost and 6
wound complications treated conservatively without sequelae. had failed by 10 years (see above). The average age of the
There were no wound problems in the comparison group. In the surviving patients was: 82.1 years (range: 68.3-94.2). Average
MO group there was one knee with poor femoral and tibial radi- Knee Society Scores (15-19 years) were 93.7 (clinical) and 57.9
oluceny scores and an additional patient with a 1.5 cm osteolytic (functional) in these aged patients. No new failures occurred
tibilal lesion In the comparison group there were no knees with and no additional surgeries were recommended or performed
poor scores. Although we found a higher rate of minor wound from 10-19 years. No case exhibited measurable polyethylene
complications, sub-optimal alignment, and late revision (5%) in wear or osteolytic lesions (lucency measuring at least 10x 5mm
comparison to a case-controlled group of non-obese patients, with loss of trabeculation and sclerotic border, consistent with
overall the problems in morbidly obese patients have been rela-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
441
PPSE 07:Layout 1 1/12/07 1:41 PM Page 442

other authors’ criteria). Using revision as endpoint, cumulative Primary TKA IR increased significantly from 6.3 in 1995 to 11.0
survivorship rate was 92.4% at 19 years. 1. No new failures after in 2004 at a rate of 6% per year (p=0.004). Revision TKA IR
10 years. 2. Non-modular prosthesis had no failures due to oste- increased significantly from 0.41 in 1995 to 0.74 in 2004 at a
olysis (unlike its modular counterpart). 3. Prosthesis likely to rate of 8% per year (p<0.001). 75 to 84 year olds represented the
outlive the patients when classical indications for age and largest increase. Revision burden remained stable. Surgical
activity (over age 65, sedentary) are respected. complications were higher in revision than primary TKA (10.1%
vs. 7.7%, p=0.007). 90 day complication rates for primary and
PAPER NO. 296 revision TKA include death (0.3% and 0.6%) and pulmonary
Minimum 10-year Results with a Contemporary embolism (0.5% and 0.4%), respectively. 90 day readmission
rates for primary and revision TKA include infection (0.5% and
Cruciate-Retaining Total Knee Arthroplasty 4.2% p<0.001), myocardial infarction (0.1% each), and pneu-
John Wesley Barrington, MD, Plano, TX (n) monia (0.2% and 0.4%), respectively. The incidence of primary
Alexander P Sah, MD, Boston, MA (n) and revision TKA increased substantially between 1995 and
Andrew A Freiberg, MD, Boston, MA (n) 2005. The rates of postoperative complications were low. The
Henrik Malchau, MD, Boston, MA (n) increase in primary as well as revision TKA performed allows
Dennis W Burke, MD, Boston, MA (n) prediction of resource allocation for the future.
Abstract: Good results have been reported at greater than 10 years
PAPER NO. 298
with early cruciate-retaining and posterior stabilized knees. Few
such long-term results exist with current prostheses. The NexGen Contrasting Patellofemoral Complications Between
(Zimmer, Warsaw, IN) is an implant used widely throughout the a Second and Third Generation Total Knee
world, and although early results are encouraging, there are no
Matthew Thomas Hummel, MD, Greenville, SC (n)
published results exceeding 7 years follow-up. 127 knees in 115
Christopher H. Kavolus, MD, Greenville, SC
patients, average age 67 years, were implanted by one surgeon
between February 1995 and December 1996. The NexGen knee (a – Zimmer, Biomet, b, e – Zimmer)
system, with cemented, modular, fixed-bearing, and cruciate- James E Jennings, MD, Greenville, SC
retaining implants and the four-peg tibia, was used for all cases. (a – Zimmer, Biomet)
All patellae were resurfaced. Patients were assessed using the Knee Abstract: This study retrospectively contrasts two cohorts of
Society scoring system at a minimum of 10 years following consecutive patients (number 202) after primary total knee
replacement. At the time of the latest follow-up, 89 patients (99 arthroplasty in respect to the types and numbers of patella and
knees) were alive. For all deceased patients, it was confirmed that extensor mechanism complications. Each patient had a primary
the knee was unrevised at the time of death. At minimum ten- total knee arthroplasty performed by one of two senior attending
year follow-up, only one patient (one knee) required a revision. joint surgeons. They had similar postoperative rehabilitation and
No remaining knees were radiographically loose. Average Knee were followed for a minimum of four years. Complications were
Society knee and functional scores were 98.4 points (range 95- diagnosed by the surgeon at the time of, or during subsequent
100 points) and 87.3 points (range 62-100 points) at latest eval- follow-up and by systematic review of pre and post operative x-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

uation. The average range of motion was 121 degrees. rays. Our results demonstrated an overall trend of decreased
Survivorship was 99% at 10 years, with revision of any compo- patellofemoral complications associated with the NexGen Legacy
nent for any cause as the failure end-point. At minimum ten-year PS system. Patella fractures decreased from 6 to 0, avascular
follow-up, cemented, modular, fixed-bearing, cruciate-retaining necrosis from 9 to 0, and lateral retinacular release from 24 to 14.
total knee arthroplasty using the NexGen knee demonstrated The Insall ‘ Salvanti ratios did not differ between implant types.
excellent, durable clinical and radiographic results. We recom- The IB-II has a higher incidence of patella fracture, avascular
mend continued use of this knee system. necrosis and lateral release. The alteration and adjustment of the
patellofemoral dimension in the NexGen Legacy design to a
PAPER NO. 297 more anatomical, extended design of the femoral component
17,080 Knee Replacements: Epidemiology, and patella modifications led to an increased contact area. The
incidence of complications was decreased.
Outcomes, and Trends
Monti Khatod, MD, Santa Monica, CA (n) PAPER NO. 299
Stefano Alec Bini, MD, San Francisco, CA (n) Analysis and Correction of Pathological Gait
Robert S. Namba, MD, Irvine, CA
Patterns and Functional Problems after TKA
(a – Depuy, Zimmer, Smith and Nephew)
Maria Carolina Secorun Inacio, MS, Irvine, CA (n) Anil Bhave, MS, Baltimore, MD (n)
Liz Paxton, MA, San Diego, CA (n) Thorsten M Seyler, MD, Baltimore, MD (n)
Donald C Fithian, MD, El Cajon, CA (n) Roland Starr, MS, Baltimore, MD (n)
Johannes F Plate, BS, Heidelberg, Germany (n)
Abstract: Population-based data on the utilization, outcomes,
and trends in total knee arthroplasty (TKA) are limited. The Michael A Mont, MD, Baltimore, MD (n)
purpose of this study was to examine TKA utilization and short- Abstract: Although most patients have excellent clinical results
term outcomes in a pre-paid health maintenance organization, from total knee arthroplasty (TKA), some patients are dissatisfied
and to determine if rates and revision burden changed over time. with their functional results, due to various biomechanical imped-
Using hospital utilization and membership databases from iments not directly associated with their TKA. The purpose of this
1995 to 2004, we calculated incidence rates (IR) of primary and study was to identify the biomechanical abnormalities in patients
revision TKA per 10,000 health plan members. 15,943 primary as assessed by muscle examinations, gait evaluations, and isoki-
TKA and 1,137 revision TKA were performed in a 10 year period. netic strength testing. Forty-one patients (age range: 45 to 83
Patients under 65 accounted for 33.7% of all replacements. years) had a total knee arthroplasty with persistent pain with no
identifiable abnormalities noted on radiographic evaluation. All

442 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 443

patients underwent biomechanical assessment including careful PAPER NO. 496

physical examination, videotape analysis, 3-dimensional gait Navigation in Total Knee Replacement: Is it worth it?
studies, and isokinetic strength testing. Abnormalities identified
were corrected with a multi-modal approach which included Carlos J Lavernia, MD, Coral Gables, FL (a – Zimmer,
aggressive physical therapy, customized knee devices (CKD), injec- Medtronic, e – Zimmer, Orthosoft, d – Zimmer)
tion of Botulinum toxin, quadriceps strengthening using electrical Jan Hommen, MD, Miami, FL (n)
stimulation, shoe lifts, orthoses, and peroneal nerve release. Victor Hugo Hernandez, Miami, FL (n)
Twenty-three patients had muscle tightness (gastrocnemius, Michele R D’Apuzzo, MD, Miami, FL (n)
hamstrings) demonstrating increased knee flexion at initial stance Abstract: Computer-Assisted Orthopaedic Surgery (CAOS) has
and increased mid-stance knee flexion with a plantar-grade foot. received significant attention in the orthopaedic literature. An
Four patients demonstrated functional malalignment of the exhaustive search of the literature demonstrated no published
involved side. Three of these patients demonstrated abnormal foot articles on the cost utility of CAOS. The cost of a navigation
mechanics (plano valgus foot) that led to increased valgus loading system in the U.S. today varies from $55,000 to over
of knee joint, and one patient exhibited ligamentous laxity that $400,000.Our objective was to assess the cost utility of CAOS. A
resulted in rotational malalignment. Five patients had leg length consecutive sample of 32 patients, (age of 73±2.0SE), having a
differences measuring up to 1 to 2.5 cm with all having a long leg unilateral TKA for end-stage osteoarthritis were studied. All
on the involved side, resulting in knee flexion compensation. surgeries were performed using electromagnetic computer-
Eighteen patients had quadriceps muscle weakness, leading to assisted (EM). To measure the potential marketing impact, we
knee flexion in stance to stabilize the knee. Three patients had recorded the number of calls made to the office two weeks before
peroneal nerve entrapment, resulting in a flexed knee posture. and two weeks after a web casting of a TKA using EM. We also
Successful outcome as measured by improved gait and range of develop an economic model to get the potential benefits from
motion was obtained in 38 out of 41 patients with the aggressive the navigation system. The average total surgical time for the TKA
therapy protocol. One patient with severe ligamentous laxity time was 1:30:05±0:02:40 SE for the navigated cohort and
required revision of the implant. Detailed biomechanical asses- 1:07:02±0:01:41 SE minutes for the cohort without navigation
ment including 3-dimensional gait studies and videotape analysis (p<0.001). In TKA the major quantifiable benefit obtainable by
are extremely useful in identifying biomechanical abnormalities improved implant positioning would be a reduction of the revi-
and dysfunction in patients after TKA who demonstrate no sion rate due to aseptic loosening, In order to realistically model
obvious radiographic abnormality, but still show clinical prob- potential benefits we assumed that 75% of these revision cases
lems related to malalignment and muscle problems. The identifi- could be eliminated by proper component positioning. If 250
cation and treatment of these abnormalities led to a successful TKA per year are done only 70% of the investment is returned.
outcome in 92% of patients treated. However if assume elimination of all the revisions the investment
is returned with 300 surgeries per year. A total of 419 calls, were
PAPER NO. 300 done, 168 calls for new appointments before and 239 after the
Predictors of Patient Expectations for HTO vs TKA webcast, the mean numbers of calls per day asking for new
William I Sterett, MD, Vail, CO appointments before the web casting were 13+/-1.2S.E and after

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

(a – Smith & Nephew, EBI, Genzyme, c, e – EBI) 21 +/-1.9 S.E (p=0.002). In primary knee surgery the benefits do
not catch up with the costs when the average reported added time
Lauren M Matheny, BA
is modeled. In TKA CAOS does not become cost effective unless
(a – Smith & Nephew, EBI, Genzyme) the model is changed to assume elimination of all revisions.
Karen K Briggs, MPH, Vail, CO
(a – Smith & Nephew, EBI, Genzyme) PAPER NO. 497
Abstract: The purpose of this study was to determine if patient What Have We Learned After 300 Electromagnetic
expectation of treatment was different between patients under-
going high tibial osteotomy (HTO) and total knee replace- Guided MIS TKR?
ment(TKR). Thirty-five patients (15 female, 20 male) with an David R Lionberger, MD, Houston, TX (e – Zimmer)
average age of 55 years (range, 20-84) were given a subjective David Ho, BS (e – Zimmer)
and patient expectation questionnaire prior to surgery. Patient Lindsey Law (e – Zimmer)
expectation, Lysholm, and Tegner scores were determined. Gnoc A Nguyen (e – Zimmer)
Twenty-two patients underwent HTO and 13 underwent TKR. Philip C Noble, PhD, Houston, TX (e – Zimmer)
In this study, males were more likely to have an HTO procedure
Abstract: Use of electromagnetic navigation technology in TKR
than females (p=.032). Tegner scores were shown to be higher
has allowed miniaturization of trackers, providing benefits for
preoperatively in HTO patients (3.3) than TKR patients (2.1)
procedures through smaller incisions. In this study, we review
(p=.047). No difference was seen in preoperative Lysholm
the first 300 cases of TKR performed by a single surgeon using
scoresl. Expectations in HTO patients were higher than expecta-
this system. Three hundred TKR procedures, performed by a
tions in TKR patients for ability to squat (p=.025), ability to
single surgeon using EM navigation were reviewed prospectively
kneel (p=.044), ability to run (p=.013) and stopping knee stiff-
on the basis of a clinical and radiographic review. Alignment of
ness(p=.009); however, patients confidence in their knee was
all implanted components was assessed with 36’ radiographs.
more important to TKR patients than HTO patients (p=.044).
Outliers were defined as cases where the final alignment of the
HTO patients were more likely to be male and younger. HTO
knee was > 3º from the mechanical axis. Knee Society scores
patients also had higher expectations for squatting, kneeling,
were determined with complications documented intraopera-
runinng and knee stiffness; however, confidence in their knee
tively. Femoral sizing was consistently overestimated by the
was more important to TKR patients. Patient expectations may
current version of the EM program. The complications included
be important in determining surgical treatment. Patient expec-
3 MUA’s (1.0%), 4 revisions due to fracture or instability (1.3%),
tations should be matched with expected outcome of surgical
and one infection (0.3%). Two of the revisions were due to
intervention.
misalignments not recognized by CAS. There were mechanical

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
443
PPSE 07:Layout 1 1/12/07 1:41 PM Page 444

alignment errors of > 3º in 4.4% of cases. In 5 cases (1.7%), in TKR patients were included, of which 68 had standard TKR and
which larger components were implanted, the system would not 68 computer assisted. Patients were matched such that in each
track due to metal interference. This problem was less frequent group half had BMI in the range 20-30, and half had BMI between
when trackers were placed very remotely from the surgical site. 30-40. Patients were also matched for gender. All patients had
Operative time using the EM program was longer than the tradi- Tranexamic acid at the start of the procedure. Total body blood
tional procedures by 6.5 minutes. Knee scores improved by an volume was calculated using the formula of Nadler, Hidalgo &
average of 79.7%. One disturbing finding regarding instrumen- Bloch (1962). This was then used, together with haematocrit and
tation rather than computers is the 0.7% incidence of fracture on volume re-infused or transfused, to calculate true blood loss, as
the medial plateau due to fixation penetration. Though EM CAS described by Sehat, Evans, and Newman (2004). This method is
provides acceptable guidance for MIS TKR, it is important to considered to be more reliable than measuring drain output, as it
remember that metal interference and erroneous readings are takes account of “hidden” losses. The navigated and non-navi-
still possible. In these cases, the surgeon must rely on common gated groups were compared using Student’s t-test. The average
sense and manual estimates of alignment. CAS can make accu- blood loss was 603ml in the standard TKR group, and 448ml in
racy more consistent but is no substitute for surgeon intuition. the computer assisted TKR group. This difference was statistically
significant (p = 0.007). A previous study found reduced blood loss
PAPER NO. 498 when performing total knee replacement using computer naviga-
Alignment and Orientation of the Total Knee tion, compared with traditional methods. Our study confirmed
this finding, using a larger sample size, and a more reliable
Components with and without Navigation Support method of assessing blood loss. Our study found that overall
Young-Hoo Kim, MD, Seoul, Republic of Korea (n) blood loss was less for both groups, when compared to the find-
Jun Shik Kim, MD, Seoul, Republic of Korea (n) ings of Kalairajah Y et al. We suspect that this difference was due
Dae-Ya Kim, MD, Seoul, Republic of Korea (n) to our departmental policy that all patients receive tranexamic
Abstract: We conducted a prospective and randomized study to acid at the start of joint replacement procedure.
investigate the hypothesis that computer-assisted procedure
would lead to better orientation and alignment of the compo- PAPER NO. 500
nents. Each of the 100 patients used a navigation system on one Embolic Phenomena During Computer-Assisted
side and a conventional technique on the contralateral side. The and Conventional Total Knee Arthroplasty
mean age was 67.6 years (range, 54 to 83 years). Eighty-five
patients were women and fifteen were men. Clinical and radi- Gregory Clayton Janes, MB, West Perth, WA Australia (n)
ographic evaluations were done preoperatively, three months, Sam Church, FRCS, London, United Kingdom (n)
one year after the operation and yearly thereafter. Also, the John Scadden, FRCS, Isle of Wight, United Kingdom (n)
prevalence of outliers between computer-assisted and conven- Rohit R Gupta, MD, Surrey, United Kingdom (n)
tional groups were examined. Postoperative computer tomogra- Abstract: Systemic embolic phenomena are well recognised
phies using a multi-slice scanner were performed to determine during total knee arthroplasty (TKA) and are widely believed to
the rotational alignment of femoral and tibial components. The be the cause of intra-operative hypotension and reduced cardiac
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

mean follow-up was 2.3 years (range, two to three years). output, which may lead to circulatory collapse and sudden
Operating and tourniquet times were significantly (P<0.001) death. This double-blind, randomised, controlled study was
longer in the navigation group. Total knee score (90 vs 89 designed to prospectively compare the cardiac embolic load
points), pain score (40 points in each group), range of motion during computer-assisted and conventional, intramedullary-
(127° vs 126°) were not statistically different (P>0.05) between aligned TKA. The embolic load during 26 TKAs (14 computer-
two groups. The alignment of the knee, the position of the assisted, 12 standard) was continuously monitored using
femoral and tibial components, patellar angles, tibial surface transoesophageal ultrasound. The recordings obtained were
capping, and preoperative and postoperative joint lines were not scored using the modified Mayo Clinic grading system for
significantly different between two groups (P>0.05). The preva- echogenic emboli. Patients undergoing conventional TKA had a
lence of outliers was not statistically different between two mean embolic score of 6.15 (± 0.83) on release of the tourni-
groups (P>0.05). We were not able to prove our hypothesis that quet. Those undergoing CA-TKA had a mean embolic score of
the computer-assisted procedure would lead to better orienta- 4.89 (± 1.10). Comparison of the groups using a two-tailed t-test
tion and alignment of the components. shows a significant difference (p=0.004). The results confirm
there is a significant reduction in the cardiac embolic load in the
PAPER NO. 499 computer-assisted TKAs when compared with standard
Blood Loss Following Total Knee Replacement (TKR): TKAs.There is published evidence that this is likely to reduce
intra-operative and post-operative morbidity. This would appear
Computer Assisted Versus Standard Techniques
to add to the ever-growing list of compelling arguments in
John Dillon, MRCS, Glasgow, United Kingdom (n) favour of computer-assisted total knee arthroplasty.
Jamie McConnell, MBChB (n)
Abstract: Computer navigated total knee replacement does not PAPER NO. 501
require the use of intramedullary alignment rods, and is thus less Transepicondylar Distal Femoral Pin Placement in
invasive than traditional methods. One previous study has
suggested that the computer-assisted technique may reduce blood Computer Assisted Surgical Navigation
loss in comparison to traditional methods. This study (Kalairajah James B Stiehl, MD, Milwaukee, WI (*)
et al, 2005) used blood volume loss from drainage bottles as a Abstract: The use of optical tracking systems in computer assisted
primary outcome measure (n=60). Hidden (internal) blood surgical navigation requires the rigid fixation of a dynamic refer-
losses were not accounted for. Our study uses a more accurate ence base to the target bone to be navigated. This report presents
method of assessing blood loss, and the sample size is larger the results of a new approach for optical tracker fixation in the
(n=136; 68 standard TKR versus 68 computer assisted TKR). 136 distal femur. Four embalmed cadavers were evaluated for pin

444 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 445

placement and it was found that placement of pins from medial PAPER NO. 503
to lateral parallel the transepicondylar axis placed the pins well Minimally Invasive Total Knee Arthroplasty Using
posterior to the center of the intramedullary canal and away
from neurovascular structures. 86 consecutive patients under- the Contralateral Knee As A Control Group
went total knee arthroplasty using this new technique. Pin place- Peter M Bonutti, MD, Effingham, IL
ment was percutaneous with the pin site entry initiated by direct (e – Stryker Howmedica)
palpation of the medial epicondyle through an MIS incision. All Michael A Mont, MD, Baltimore, MD
procedures were successful for performing a navigation assisted (e – Stryker Howmedica)
total knee replacement. Obesity was not a factor nor was there Margot McMahon, RN, Effingham, IL (n)
loosening of the pin array during the procedure. There were no
German A Marulanda, MD, Baltimore, MD (n)
wound healing problems in any patient. At one year follow-up,
no patient could identify subjective symptoms related either to Abstract: Multiple reports have evaluated minimally invasive total
the medial epicondylar area or the stab wound portals. There knee arthroplasties. Although some studies show shorter hospi-
were no direct neurovascular injuries noted and no patient talizations and rehabilitation periods, other studies find mini-
developed fracture of the femur related to the pin sites. mally invasive approaches to offer no benefit to standard
Neurovascular injury and stress fracture are significant compli- techniques with sometimes increased complication rates. In this
cations that may result from placement of distal femoral pins for study, the investigators compared total knee arthroplasties in
optical computer navigation in TKA. This report describes a new which a standard total knee replacement was initially performed
technique that facilitates pin placement for minimally invasive on one knee and a minimally invasive total knee replacement
approaches eliminating complications. Sagital plane array orien- (MIS) was performed later on the contralateral side to serve as a
tation simplifies the surgical technique. control. Twenty-five patients (50 total knee arthroplasties) were
evaluated. A MIS approach (quadriceps sparing, no patellar ever-
PAPER NO. 502 sion, small incision length-<12 cm) was used on one side with a
standard approach on the contralateral knee (medial parapatelar,
MIS-TKA is Really MIS ?: A Comparison of patella eversion, incision length >16 cm). Clinical variables such
Muscle-Related Enzymes Between MIS and as time to recovery, visual pain scales, and patient satisfaction
Conventional TKA scores were evaluated at post-operative visits. In addition, post-
operative radiographic reviews for alignment variables were
Yasuo Niki, Tokyo, Japan (n)
performed in all patients. The standard knee replacement was
Takeshi Mochizuki, MD (n) performed using a conventional medial parapatellar approach.
Hideo Matsumoto, MD, Tokyo, Japan (n) Isokinetic strength testing was performed in all knees at 3 months
Toshiro Otani, MD, Tokyo, Japan (n) follow-up post-operative. Twenty-two of the 25 patients preferred
Atsushi Funayama, MD, Tokyo, Japan (n) the minimally invasive approach. One patient noted no difference
Shinichi Maeno, MD, Tokyo, Japan (n) and two patients preferred the standard approach. All 25 patients
Fumihiro Yoshimine, MD, Tokyo, Japan (n) noticed a cosmetic difference with a significantly shorter incision,
(mean of 8.5 cm, range, 6-11 cm) versus a standard incision

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Yoshiaki Toyama, Tokyo, Japan (n)
Koichiro Komiya, MD (n) (mean of 18 cm, range, 16to 26 cm). Isokinetic testing demon-
strated statistically improved quadriceps strength in the minimally
Abstract: Numerous reports on minimally invasive total knee
invasive technique group at 3 months compared to standard at 1
arthroplasty (MIS-TKA) have adovoated more rapid functional
year. Seventeen of 25 patients were able to generate more quadri-
recovery. However, it still remains unknown whether MIS-TKA
ceps peak torque when compared to the contralateral standard
actually minimize soft tissue damage. In this study, the degree of
incision arthroplasty at 3 months post-operative. Radiographic
surgical damage was evaluated by measuring serum levels of
analysis did not reveal differences in alignment variables between
muscle-related enzymes. A consecutive series of 125 knees from
the two approaches. The literature shows that the conventional
115 patients who underwent primary TKA were enrolled
total knee arthroplasty with everted patellas and traditional para-
(MIS:75; conventional:50). Of 75 MIS-TKAs, only 5 were
patellar approaches can lead to as a 30 % reduction in quadriceps
performed with quadriceps-sparing approach, and 70 extended
strength. The results of this study suggest that minimally invasive
the arthrotomy into 37 subvastus, 26 midvastus, and 7 parap-
total knee arthroplasty offers some short-term as well as possible
atellar with minimal disruption of the suprapatellar pouch and
long term functional improvement as evidenced by patient satis-
no eversion of the patella. Conventional TKAs were comprised
faction and quadriceps strength variables.
of 23 subvastus, 7 midvastus, and 20 parapatellar approaches.
Serum levels of CPK, myoglobin, aldorase, LDH, GOT, and CR PAPER NO. 504
were measured at 0-, 1-, 2-, 4-, 7-, and 14-day postoperatively.
Rising index (RI) was calculated as a percentage of preoperative Does Skin Length Matter in Minimal Invasive Total
value and the peak value of RI (RIpeak) was determined in each Knee Arthroplasty?
enzyme. Serum levels of CPK and myoglobin peaked at 1-day Emmanuel Thienpont, MD, Asse, Belgium
postoperatively, whereas LDH and GOT peaked at 7-day post- (e – Stryker, Smith & Nephew)
operatively. Aldorase displayed two peaks at 1- and 7-day post-
Abstract: In a previous study minimally invasive (MI) total knee
operatively, while CR remained constant throughout the
arthroplasty (TKA) was performed through a 12 cm incision
postoperative period. Unexpectedly, none of the RIspeak of
and at the end of the surgery in half of our patients the skin inci-
various enzymes displayed no statistical differences between
sion was extended to 20 cm. No differences were found in clin-
MIS- and conventional TKA. Basically, RIpeak of each enzyme
ical results. In this study we analyzed potential advantages of
was equivalent between the 4 types of vastus-splitting
performing MI TKA through a bigger incision from the begin-
approaches. From the perspective of muscle-related enzymes,
ning of the procedure. Prospective randomized study. Sixty MI
the degree of surgical damage in quadriceps muscles was equiv-
TKA were performed through a 12 cm or a 20 cm skin incision
alent between MIS- and conventional TKA.
and a mini-midvastus approach. Data was collected on: tourni-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
445
PPSE 07:Layout 1 1/12/07 1:41 PM Page 446

quet time, blood loss, skin bruises, VAS, use of morphine pump, were followed with Knee Society Scores, SF 36 and radiographic
range of motion, straight leg raising, time to independent exams. They were compared to historical controls. At six month
ambulation, length of stay, wound problems and complications follow up, was a statistically significant, higher rate of minor and
up to 6 weeks, KSS and alignment. Tourniquet times were major wound complications, especially in patients with prex-
significantly shorter, less skin bruises and less outliers of the isting vascular disease. There was no difference in knee scores,
alignment were observed in the 20 cm group. For all the other SF36 or radiographic outcomes between the study and control
parameters there was no statistical difference between both group While quad sparing total knee replacement is relatively
groups. Minimal skin length is a non issue in MI total knee safe, there was a higher rate of wound complications without
arthroplasty. A longer incision avoids the many manipulations benefit at 6 month followup.
to use the mobile windows and cutting the tibia in extension.
Better tibial alignment is obtained with a suffiicient distal inci- PAPER NO. 507
sion. Patients benefits are obtained by less soft tissue damage Retractor Forces During Standard and Minimally
and by avoiding patellofemoral and tibiofemoral dislocation.
Performing MI total knee arthroplasty through a comfortable
Invasive TKA
incision is advantageous. Shorter operating time, use of Daniel T Le, BA, Houston, TX (n)
habitual techniques, less skin bruising and avoidance of skin- Michael A Conditt, PhD, Houston, TX (a – Zimmer)
implant contact can be obtained. Nikhil Kulkarni, MS, Houston, TX (a – Zimmer)
Sabir Ismaily, BS, Houston, TX (a – Zimmer)
PAPER NO. 505 James M Saucedo, BA (n)
Complication Rate after Knee Arthroplasty Philip C Noble, PhD, Houston, TX (a – Zimmer)
Performed with Quadriceps Sparing or Standard Abstract: In TKA, smaller incisions have been proposed to
Arthrotomy preserve the extensor mechanism, potentially accelerating post-
operative recovery. However, a shortened medial incision also
Young-Hoo Kim, MD, Seoul, Republic of Korea (n) increases demands on the surgeon to gain exposure to the
Jun Shik Kim, MD, Seoul, Republic of Korea (n) femoral condyles to align the appropriate cutting blocks. The
Keun-Soo Sohn, MD, Seoul, Republic of Korea (n) purpose of this study was to measure the retractor forces
Abstract: The purpose of this prospective and randomized study required to gain full visibility of the femoral condyles during
was to compare the results of primary total knee arthroplasty standard and minimally invasive knee replacement procedures.
performed with a quadriceps sparing (QS) or a standard arthro- Five experienced joint replacement surgeons implanted a poste-
tomy. A consecutive series of 120 patients who underwent rior-stabilized TKA in 5 fresh cadavers. On one side, the proce-
primary bilateral simultaneous total knee arthroplasties (120 dure was performed using standard instrumentation via a
with the use of a QS approach and 120 with the use of a stan- standard 13cm mid-vastus incision. On the other side, a 10cm
dard arthrotomy) were studied. The clinical and radiographic subvastus capsular incision was used with specialized mini-inci-
results, pain scales, surgical and hospital data, and complica- sion instruments. The patella was routinely everted in the stan-
tions were compared. The estimated blood loss was not different dard incision but not during the smaller incision procedures.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

between the 2 groups. No significant differences were found The force required to expose the femoral condyles at ninety
between the two groups with respect to the knee score, pain degrees of flexion was recorded for both the medial and lateral
scale, range of motion, or radiographic results at 2 weeks, 3 Hohman retractors. With a standard incision, the force required
months, 1 year, and 2 years postoperatively. In contrast, the to expose the distal femur at 90 degrees of flexion for both
operating (P=0.0001) and the tourniquet times (P<0.0001) were medial and lateral retractors was less than 3N for every spec-
significantly longer in the QS group. Also, complications imen. With the MIS incision however, the force required to
including anterior femoral notching supracondylar femoral frac- expose the distal femur at 90 degrees of flexion measured 8.9 ±
ture, inadvertent quadriceps tendon laceration and superficial 3.1N for the medial retractor compared to 28.5 ± 8.9N for the
and deep infections were significantly more frequent in the QS lateral retractor. Forces on the retractors required to expose the
group (P=0.0468). Despite there were no differences in most joint during TKA are significantly higher during minimally-inva-
clinical and radiographic parameters between the two groups, sive approaches. With smaller incisions, care must be taken to
the operating time was longer and the early complication rate protect the exposed, cut patella and the patellar tendon to avoid
was higher in the QS group. damage caused by the lateral retractor as retraction forces aver-
aged three times higher laterally than medially.
PAPER NO. 506
Complications following Quad Sparing Total Knee PAPER NO. 508
Replacement Applicability of the Mini-Subvastus Total Knee
Barry J Waldman, MD, Baltimore, MD Arthroplasty Technique
(a – Biomet, Encore Medical) William C Schroer, MD, Saint Louis, MO (a, e – Biomet)
Gabriel Jackson, MD, Washington, DC (n) Paul Diesfeld, PA-C, Saint Louis, MO (a – Biomet)
Abstract: There has recently been increased interest in soft tissue Mary E Reedy, RN, Saint Louis, MO (a – Biomet)
sparing knee replacement. Difficulty with alignment, ligament Angela LeMarr, RN, Saint Louis, MO (a – Biomet)
balancing, cement retention and excess skin damage are all Abstract: Recent total knee arthroplasty (TKA) studies suggest a
possible with less invasive techniques. We prospectively more rapid functional recovery with minimally invasive surgical
followed 209 consecutive patients who underwent quad sparing, (MIS) techniques. Many studies list selection criteria for the MIS
less invasive total knee replacement. All patients had the same procedure, but fail to disclose the applicability of the MIS proce-
implant, surgeon and clinical pathway. The technique involved dure to their primary TKA practice. This raises the concern that
incisions of 10 cm or shorter and a median parapatellar incision positive clinical outcomes are a result of patient selection rather
with a less than 2 cm extension into the vastus medialis. Patents than surgical technique. This study evaluates the applicability of

446 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 447

the mini-subvastus technique in our primary TKA patients. cardiovascular rehabilitation and general fitness. The authors
Computer records were reviewed for primary TKA, CPT code created a music exercise video for use in the postoperative period
27447. All procedures were performed by the principle investi- following total knee replacement. A prospective study was done
gator using a cemented posterior-stabilized implant. Surgical whereby 45 patients undergoing 51 primary total knee replace-
records were examined to determine the surgical technique, ments were randomized to a control (25) or video (26) group.
patient age, BMI, weight, deformity, and knee diagnosis. The mini- All procedures were done by the senior author. Patients were
subvastus technique was employed in 725 (99%) of 732 consec- then evaluated at postoperative weeks 1,2,4,6, and 8 by a
utive primary TKA. Seven knees underwent a traditional TKA blinded examiner who generated Knee Society scores. Patients
(1.0%) with a medial parapatellar (MPP) arthrotomy. In no also completed a satisfaction questionnaire and the 8 week cost
surgery was the MIS procedure abandoned in favour of a tradi- of rehabilitation was documented. Significant improvements
tional approach. The two groups of TKA patients had similar age, were noted in patient’s assessment of understanding, confi-
weight, and BMI. Knee deformity was not significantly different dence, and overall satisfaction when using the video. Average
between the two TKA groups with a mean deformity of 9º for the return to usual activities was 34 days in the control and 14 days
MIS group (range 0º to 30º, SD 4.2º) and 12º for the MPP group in the video group. Knee Society scores were improved for the
(range 5º to 27º, SD 6.6º), p=0.11. Compared with the MIS video group and the differences were statistically significant at 6
patients, the traditional TKA patients had an increased incidence and 8 weeks. The therapy costs averaged $2,602.00 in the control
of post-traumatic arthritis (43% vs. 2%, p<0.01) and more often and $287.00 in the video. No complications were reported
required tibial stems or augments at the time of surgery (71% vs. while using the video. Use of the music video as a supplement
0.3%, p<0.01). The mini-subvastus approach was applicable to to the rehabilitation program in the early postoperative period
99% of our primary TKA. There was no patient selection based on following total knee replacement is recommended due to
age, weight, or BMI. The preoperative tibiofemoral angle and improved patient satisfaction, earlier return to activities, and
mean knee deformity were not predictors of which procedure improved 6 and 8 week knee scores. These are achieved at a
would be utilized. Traditional TKA were more likely to be substantial cost savings which benefits both patients and society.
performed on those patients with a diagnosis of traumatic arthritis
or in knees that required stems or augments. This high applica-
bility rate with the mini-subvastus technique obviates concerns
that positive clinical outcomes are a result of patient selection.
POSTERS
PAPER NO. 509 POSTER NO. P111
Long Term Quadriceps Strength Retention After An Dynamic In Vitro Measurement of Quadriceps
MIS-TKA with A Mini Midvastus Approach Extension Force after Non-Hinged and Hinged TKA
Scott D Schoifet, MD, Mount Holly, NJ (a, e – Stryker) Sven Ostermeier, Hannover, Germany (n)
Tom Depaulis, MPT, Mount Laurel, NJ (n) Christian Friesecke, MD, Hamburg, Germany (n)
Kristen Lehmann, PA, Lumberton, NJ (n) Sebastian Fricke, MD, Hanover, Germany (n)

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Abstract: Long term quadriceps strength deficits have been Christof Hurschler, PhD, Hannover, Germany (n)
reported after a TKA performed with a quadriceps splitting
Christina Stukenborg-Colsman, MD, Hannover, Germany (n)
approach. Will an MIS-TKA performed with a mini midvastus
approach significantly improve long term quadriceps strength Abstract: Biomechanical changes after total knee arthroplasty
retention? 147 subjects were chosen for this study. 52 MIS-TKA, have been observed: the lever arm of the extensor mechanism
48 quadriceps splitting TKA, and 47 controls with normal knees was decreased due to a paradoxical movement of the femur rela-
and no prior knee surgery. All groups were age and gender tive to the tibia, which resulted in higher quadriceps muscle
matched. All knees were tested more than 1 year after the index force required to extend the knee. The purpose of this in vitro
operation on a Cybex isokinetic dynamometer. All surgeries study was to investigate the amount of quadriceps force required
were performed by the lead author. The average Knee Society to extend the knee during an isokinetic extension cycle before
knee score for the MIS-TKA group is 94.3 and the quadriceps and after a non-hinged and hinged total knee arthroplasty.
splitting group is 95.7. At 30 degrees from full extension the Human knee specimens (n=6, mean age=65 SD 7 years) were
MIS-TKA group has 96.6% of the control group strength and the tested in a kinematic knee simulator in physiologic conditions,
quadriceps splitting group has 94.5%. At 15 degrees from full after TKA of a non-hinged cruciate retaining prosthesis
extension the MIS-TKA group improves to 99.7% while the (Gemini®, Link, Germany) and a hinged prosthesis (Rotations-
quadriceps splitting group falls to 85% of the control group Knie®, Link, Germany). During simulation of an extension cycle
strength. MIS-TKA with a mini midvastus approach preserves from 120° knee flexion to full extension, the change of quadri-
terminal quadriceps strength better than a standard quadriceps ceps force to produce the constant extension moment was
splitting approach. dynamically measured using a load cell attached to the quadri-
ceps tendon. After Implantation of the non-hinged Gemini®-
PAPER NO. 510 prosthesis maximum quadriceps force did not alter in flexion,
but significantly increased to 1257 N (SD 273 N, P=0.04) in
Postoperative Total Knee Replacement knee extension. Following the implantation of the hinged pros-
Rehabilitaion: A New Method Using Music Video thesis quadriceps extension force significantly decreased to 690
Thomas G Ryan, MD, Kalamazoo, MI (n) N (SD 81 N, P=0.003) in extension. Hinged knee prosthesis
Blake Lamonte Ohlson, MD, Baltimore, MD (n) probably improve the quadriceps lever arm due to higher
Ryan L Adams, MPT (e – Physiotherapy Associates Stryker) constraint and knee joint stability. This would offer a potential
advantage for patients with high morbidity and weaker quadri-
Abstract: Postoperative rehabilitation protocols following total
ceps strength to achieve sufficient knee strength and mobility
knee replacement vary considerably among surgeons. Previous
after total knee arthroplasty.
reports have shown the usefulness of music exercise videos for

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
447
PPSE 07:Layout 1 1/12/07 1:41 PM Page 448

POSTER NO. P112 knees were revised for infection. All patients were followed
Rhbmp-2/Calcium Phosphate Matrix Accelerates prospectively; KneeSociety Knee Scores were obtained. Average
follow-up is over six years. According to KSKS all patients even-
Open-Wedge Tibial Osteotomy-Site Healing In tually benefitted; the average improvement was over 85
Gonarthrosis points.Six revised knees failed: two by loosening, one by infec-
Philippe Hernigou, PhD, Creteil France, France (a – Wyeth) tion, one by fracture, and two by component “spin-out.”None of
Alexandre Poignard, MD (n) the knees revised for infection have failed. Histology obtained
from failed knees has shown viable bone graft. Although the
Alexandre Valentin, MD, Belmont, MA (e – Wyeth)
failure rate was high [over 10%], only two [4%] knees failed by
Abstract: The present study evaluated the ability of rhBMP-2, loosening and all knees were selected for having extensive bone
administered in a new particulating calcium phosphate matrix, loss. Thus, this experience suggests that failed knees, even with
to accelerate human high tibial osteotomy-site healing following significant bone loss and infection can be reconstructed, lost
open wedge technique. The technique was an open-wedge high bone reconstituted and a durable construct obtained using
tibial osteotomy without bone grafting. The osteosynthesis was impacted morcelised allograft bone.
done with plate and screws. The rhBMP-2/calcium phosphate
matrix was administered three days after surgery to the POSTER NO. P114
osteotomy site with a percutaneous injection under local anes-
thesia. With use of aseptic technique, a needle with the stylet in
Early Results of Profix Knee Arthoplasty System
place, was positioned in the osteotomy site with use of fluoro- Younus Hanif Khan Lodhi, FRCS, MCH orth, Galway,
scopic visualization. The stylet was removed, and 1 or 2 mL of Ireland (b – Profix Co Ltd)
rhBMP-2/calcium phosphate matrix was distributed in the Rajesh Sarin, MD, Ramsbottom, United Kingdom (n)
osteotomy site. Radiographs were made preoperatively, postop- Hans Marynissen, MD, Burnley, United Kingdom (n)
eratively, after injection, and regularly thereafter for 2 years. A Abstract: The purpose was to review early clinical result of Profix
radiograh evaluation with reproducibility of limb positioning knee Arthoplasty System This prospective study analyzed data
was performed at each visit. These 6 patients were compared from 178 consecutive Total Knee Arthoplasties without patella
with two historical control groups performed with the same resurfacing performed in 165 patients using Profix Total Knee
technique of opening wedge osteotomy . The patients were Arthoplasty System. Patients were reviewed preoperatively and at
chosen so that the size of the opening could be matched in the one year, 3 yrs and 5 yrs postoperatively. All patients had clinical,
different groups. The first control group (6 patients) had the radiological assessments and were scored by American Knee
same technique with autologous bone grafting and without of Society Score (AKSS) at each visit by independent assessor. Mean
rhBMP-2/calcium phosphate matrix. The second control group age at surgery was 68 years (40-87). Mean Height was 166
(6 patients) had the same technique without bone grafting and centimeters (130-196). while mean Weight was 74 kilograms
without of rhBMP-2/calcium phosphate matrix. The volume of (44-116). Most common diagnosis was Osteoarthritis (159
the bone defect after the opening wedge osteotomy was similar knees). Patients were followed for a mean of 38 months (8-69).
in the 3 groups: average 6.5 cubic centimeters (range 4 to 9 cubic 04 patients had superficial infection. 03 Patients died before 3
centimeters). Efficacy was evaluated on the basis of radiographic
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

years follow-up due to medical reason. The average range of

assessment of osteotomy-site callus formation and cortical motion was improved from 89 degrees to 101 degrees ( p value
bridging over a 2 years period. rhBMP-2/calcium phosphate <0.005) of flexion and extension was improved from 4.74
matrix was safe and well tolerated. Even when extrusion degrees to 1.5 degrees ( p value <0.005) postoperatively. To date
appeared ( 2 cases), the extruded material was progressively there were no radiological, septic or aseptic loosening and no
resorbed without calcification of the surrounded tendons or revision. AKS function score was improved from 52 preopera-
ligaments. The callus volume was greater in response to rhBMP- tively to 74 at 1 yrs and 71 at 3 year post operatively, while AKS
2/calcium phosphate matrix administered after surgery as pain score was improved from 61 preoperatively to 88 and 92 at
compared with patients of the second control group (without 1 and 3 years post-op respectively. We believe that Profix knee
bone grafting and without of rhBMP-2/calcium phosphate Arthoplasty is patella friendly implant and our early results are
matrix ) at two months after surgery. Radiographic evaluation promising. Long-term surveillance of implant is ongoing.
demonstrated that administration of rhBMP-2/calcium phos-
phate matrix 3 days after surgery accelerated osteotomy-site POSTER NO. P115
healing by compared with the findings in the second control
group. Callus area and rate of healing were similar in the rhBMP-
Does Late Cementing of the Patella in Total Knee
2/calcium phosphate matrix group and in the first control group Arthroplasty Compromise Fixation?
with autologous bone grafting. A single percutaneous injection Michael T Clarke, MD, Manlius, NY
of rhBMP-2/calcium phosphate matrix accelerated healing in (a – Stryker Howmedica)
open wedge osteotomy site. Mark A Miller, BA (n)
Kenneth A Mann, Jamesville, NY (a – Stryker Howmedica)
POSTER NO. P113
Abstract: Delay in cementation of the patellar button can occur
Revision Total Knee Arthroplasty with Impaction during TKA as it is typically the last of the three components to
Bone Grafting be placed. The goal of this study was to determine if patellar fixa-
Gary Worthington Bradley, MD, Santa Barbara, CA tion and degree of cement infiltration would diminish as the
(c – Finsbury, e – DePuy) cement becomes more viscous during later portions of the
working phase. Patellar buttons were cemented onto prepared
Abstract: This paper presents a fifteen year experience of one
cadaveric patellae using a wide range of clinically relevant appli-
surgeon using morcelized impacted allograft bone to revise 48
cation times (3 to 10 minutes). A total of sixteen cadaver patellae
failed knee arthroplasties. At least 90cc impacted bone was used
were cemented using either a standard cement (Simplex P, n=8)
in all knees; except for two knees,standard monoblock revision
or an early setting cement (Simplex SpeedSet, n=8). Once cured,
components [DePuy LCS] and no augmentswere used. Nine

448 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 449

specimens were loaded in shear using a custom fixture on a POSTER NO. P117
universal testing machine. The quantity of cement that interdig- Modular Polyethylene Exchange for Wear and
itated with bone was determined by microscopic stereology.
There was a significant positive correlation (R2=0.36, p=0.023) Osteolysis in PFC Total Knees
between working time and stiffness of the resurfaced patella William L Griffin, MD, Charlotte, NC (a, b, c, e – Depuy)
indicating that later cementing, even when close to the set time, David F. Dalury, MD, Baltimore, MD (a, b, e – Depuy)
was not detrimental to fixation. The quantity of cement that Ormonde M. Mahoney, MD, Athens, GA (a, b, c, e – Stryker)
interdigitated with bone tended to be lower when the cement Richard D Scott, MD, Boston, MA (a, b, c, e – Depuy)
was applied at an early stage rather than at a late stage (R2=0.34, Bryan Donald Springer, MD, Charlotte, NC (a – Depuy)
p=0.029). This work shows that cement can be used adequately
John Bryan Chiavetta, MD, Raleigh, NC (a – Depuy)
over the full range of the working phase without concern of sub-
optimal fixation even when in a highly viscous state as long as Thomas K Fehring, MD, Charlotte, NC (a, b, c, e – Depuy)
the button can be completely seated. Susan Marie Odum, MED, Charlotte, NC (a – Depuy)
Abstract: Wear and osteolysis have been successfully treated by
POSTER NO. P116 modular polyethylene exchange in revision hip surgery. Similar
Custom-made Angled Inserts for Tibial Coronal reports regarding revision total knee arthroplasty have discour-
aged modular exchange. The purpose of this study was to evaluate
Malalignment in Total Knee Arthroplasty the results of polyethylene exchange for wear and osteolysis in a
Alexander P Sah, MD, Boston, MA (n) single total knee design. Between 1999 and 2004, 68 knees from
Richard D Scott, MD, Boston, MA (c – DePuy) four centers were revised for polyethylene wear and/or osteolysis
James V Bono, MD, Boston, MA (a, e – Stryker) with isolated polyethylene exchange. The index polyethylene was
Bryan Donald Springer, MD, Charlotte, NC (n) gamma irradiated in air. The replacement poly was sterilized and
Thomas S Thornhill, MD, Boston, MA (c – DePuy) packaged in an oxygen free environment. Accessible osteolytic
lesions were grafted or cemented. Radiographs were evaluated for
Rahul V Deshmukh, MD, Jacksonville, FL (n)
osteolysis progression and loosening. Knee Society Scores were
Abstract: Component malalignment continues to be a common documented. At an average 38 months follow-up, there were 10
problem after total knee arthroplasty. Limb malalignment most (14.7%) failures. Nine components were re-revised for aseptic
often results from technical error and is a potential cause of early loosening and one for infection. No other patients developed
prosthetic loosening, polyethylene wear, subsequent failure, and radiographic evidence of loosening. Osteolytic lesions showed no
ultimate need for revision surgery. The use of a custom-made progression in 66 patients (97%). Average Knee Society clinical
angled polyethylene insert may allow for correction of a scores improved from 75 to 92 (p=0.001). With short term follow-
malaligned tibial tray and correct deformity, resulting in symp- up we found an 85% success rate with this procedure. We are
tomatic improvement and avoidance of component revision. cautiously optimistic about the results of modular exchange with
From 1993 to 2005, nine angled inserts were placed for the an improved polyethylene in total knee arthroplasty. However,
correction of coronal plane deformities due to tibial component additional follow-up is required to determine if the decreased
malposition. Knee Society knee and function scores were calcu-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

morbidity of modular polyethylene exchange is better than full
lated immediately preoperatively and at average 5-year follow- component revision for wear and osteolysis.
up. Standing long-length radiographs were compared to
preoperative films to determine overall alignment correction. POSTER NO. P118
Patients were surveyed regarding recovery from their insert
exchange surgery and about overall satisfaction with the proce- Functional Outcome after Revision Knee
dure. The patients averaged 71 years of age and underwent insert Arthroplasty: Difference Between Infected and
exchange on average 59 months (range, 4-140) after their index Non-Infected
procedure. Limb alignment correction averaged 6.2 degrees from
Matthew Austin, MD, Philadelphia, PA (n)
the initial deformity. Knee Society knee and function scores
improved from 67 and 69, respectively, to 88 and 90, postoper- Camilo Restrepo, MD, Philadelphia, PA (n)
atively. All patients reported excellent satisfaction with insert Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
exchange and no further surgical intervention has been required Elie Ghanem, MD, Philadelphia, PA (n)
at latest follow-up. Custom-made angled inserts proved benefi- James J Purtill, MD, Philadelphia, PA (n)
cial in this select group of patients with tibial component Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
malposition. While long-term results and the possible benefit of Abstract: Periprosthetic infection of a total knee arthroplasty can
avoiding major revision surgery remain to be investigated, be successfully eradicated by two-stage resection arthroplasty, but
angled inserts may provide a conservative method to correct there are concerns about the often poor clinical outcome after
mild to moderate tibial malalignment in selected cases. reimplantation. The objective of this prospective study was to
determine if there was any difference in functional improvement
following revision TKA in patients with infected and non-infected
failures. 93 consecutive patients undergoing revision TKA at our
institution were prospectively recruited into this study. The indi-
cation for revision TKA was PPI in 22 cases and aseptic failure in
the remaining 71 patients. Detailed patient demographics and
functional outcome using SF-36 and WOMAC functional
outcome scores were collected at base line and at various time
points after revision TKA. The baseline and two year follow up
functional scores were calculated and compared. The functional
score at the time of diagnosis of PPI (prosthesis in place) were
used for baseline comparisons. Infected patients had significantly

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
449
PPSE 07:Layout 1 1/12/07 1:41 PM Page 450

worse baseline SF-36 physical scores (32 vs. 39; p=0.04) and fluid aspirated from 168 total joint arthroplasties for fluid cell
WOMAC functional scores (41 vs. 31; p=0.01) than the nonin- count and neutrophil percentage. 33 patients with aspirations
fected group. However, at two year follow-up both cohorts had containing a red blood cell count >200/µl who had a complete
similar functional outcome. The two groups had similar baseline blood cell count performed on the same day of aspiration were
(9 vs. 10; p=0.5) and postoperative (6 vs.6; p=0.68) WOMAC included. Infection was defined by elevated ESR and CRP, posi-
pain scores. Although infected patients had lower baseline SF-36 tive aspiration culture, and/or positive intraoperative culture. The
mental scores (50 vs.58; p=0.06), they achieved similar mental cut-off value for fluid leukocyte count (>1700 cells/µl)
health at two year follow-up (66 vs. 65; p=0.85). It appears that
patients with PPI are markedly more disabled at base line than POSTER NO. P121
the non-infected cases. This prospective study demonstrates that Vascular Injury Following Total Joint Arthroplasty
infected patients benefit from revision TKA and achieve a func-
Luis Pulido, MD, Philadelphia, PA (n)
tional, pain, and mental health status at two year follow-up that
is similar to noninfected revision cases.
Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
James J Purtill, MD, Philadelphia, PA (n)
POSTER NO. P119 Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
Cognition Following Computer Assisted Total Knee William J Hozack, MD, Philadelphia, PA (e – Stryker)
Richard H Rothman, MD, Philadelphia, PA (e – Stryker)
Arthroplasty: A Case-Control Study
Abstract: Vascular injuries associated with total joint arthroplasty
Javad Parvizi, MD, Philadelphia, PA (n) are the most feared complication. The arterial and venous injury
David Tarity, BS, Philadelphia, PA (n) can occur due to direct or indirect trauma. A high index of suspi-
Craig T Haytmanek, BS (n) cion, recognition of the injury and prompt treatment, with the
Aidin Eslampour, MD, Philadelphia, PA (n) immediate availability of a vascular surgeon is vital for good
William J Hozack, MD, Philadelphia, PA (e – Stryker) outcome. Using prospectively collected data on 14093 patients
Abstract: A significant number of patients may experience undergoing total joint arthroplasty at our institution, all inci-
mental status changes following total knee arthroplasty (TKA). dences of vascular injury were identified. Detailed data regarding
Among other causes, mental status changes after TKA may be a the mode of presentation, the type and the outcome of inter-
result of fat embolism. We hypothesized that patients under- vention delivered, and the eventual functional outcome of the
going computer assisted TKA,with no intrameduallry cannula- total joint arthroplasty were determined. There were a total of 18
tion, have less prevalence of fat embolism, therefore less change vascular injuries (0.1%). The majority (10/18) of these vascular
in mental status than those undergoing non-computer assisted injuries were detected in the postoperative recovery area. 11
TKA. 100 consecutive patients undergoing primary TKA were injuries occurred after knee replacement and 7 after hip replace-
prospectively enrolled into one of two groups. Fifty patients ment. Indirect injury was the most common mechanism in TKA
received TKA using computer assisted navigation (navigation patients with popliteal artery thrombosis being the cause. In
group) and 50 patients received conventional TKA (control contrast, direct injury was most prevalent in the hip group.
group). Detailed preoperative and strict postoperative data was Fasciotomy for a diagnosed or impending compartment
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

collected. Inpatient records of oxygen saturation levels and need syndrome was performed in 7 of the 11 knee cases, and in one
for oxygen administration, vital signs, and laboratory results, as of the hip cases. One patient died of complications related to
well as details of all administered drugs were recorded. Patients vascular injury. 9 of 18 patients (50%) had launched a legal suit
were administered the Mini Mental Status Exam (MMSE) preop- against the operating surgeon. After more than 80 years of accu-
eratively, and postoperatively on each day while in the hospital. mulated experience and more than 25000 joint replacements
No difference was found between the groups regarding age, BMI, performed by 5 surgeons in our center, the vascular complica-
ASA score, and need for postoperative oxygen administration. tion still continues to occur. Patient awareness regarding this real
The mean preoperative MMSE score was 27 in the navigation problem may play a role in defraying the high likelihood of legal
group and 26 in the control group. The mean postoperative suits associated with this complication.
MMSE score for both groups was not significant from the respec-
tive baseline scores (p=0.959). Computer-assisted navigation POSTER NO. P122
surgery is being used with increasing popularity. While the bene- Survival Analysis of a Contemporary Modular
fits of this strategy may be many, minimization of postoperative Total Knee Replacement: A Large Multi-Center
cognition changes does not seem to be one of them.
9-Year Study
POSTER NO. P120 Martin William Roche, MD, Fort Lauderdale, FL
Determination of Leukocytosis of in Traumatic (a, e – DePuy, Stryke)
Joint Aspiration William P Barrett, MD, Renton, WA (a, e – DePuy, Stryke)
J Bohannon Mason, MD, Charlotte, NC
Elie Ghanem, MD, Philadelphia, PA (n)
(a, e – DePuy, Stryke)
Javad Parvizi, MD, Philadelphia, PA (a – Stryker)
Ronald K Miller, MD, Council Bluffs, IA
Abstract: Periprosthetic infection (PPI) remains the most dreaded
(a, e – DePuy, Stryke)
and difficult complication of total joint arthropalsty. Although
there is no definite diagnostic test for PPI, synovial leukocyte Wayne M Goldstein, MD, Morton Grove, IL
count have been reported to have high sensitivity and specificity. (a, e – DePuy, Stryke)
However, leukocytes introduced into the joint during a traumatic Jeffrey A Murphy, MS, Warsaw, IN (a, e – DePuy, Stryke)
aspiration can skew results and undermine the predictive value of Abstract: The purpose of this study was to evaluate the mid-term
this diagnostic test. This study intends to determine the diag- survival results and report on the failures of a second-generation
nostic value of implementing a corrective formula for interpreta- total condylar prosthesis (P.F.C. Sigma). Compared to its prede-
tion of bloody aspirations. We retrospectively analyzed synovial cessor (P.F.C.), geometric changes in the femoral component

450 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 451

and new sterilization and packaging methods were incorporated February 2001 and February 2006 were included. All surgeons
into the Sigma system. A consecutive series of 1951 prostheses attended an Oxford training course. The primary outcome was
were implanted in 1505 patients (917 females and 588 males) revision surgery to total knee arthroplasty and secondarily, revi-
between June 1996 and December 1997 at eight sites. sion surgery for any cause. Six surgeons were included and 3
have performed 80 % of the cases. Thirty three patients have
POSTER NO. P123 come to revision surgery as of October 15, 2006. Twenty one
Do Preoperative Antibiotics Decrease have been revised to total knee arthroplasty (14 cruciate
retaining and 7 posterior stabilized), and the other to fixed
Intraoperative Culture Yield? bearing unicompartmental replacement. Causes for revision
Elie Ghanem, MD, Philadelphia, PA (n) arthroplasty included lateral compartment deterioration (9),
Jesse Richman, BS (n) persisting medial pain (4), inappropriate patient selection (4),
Robert L Barrack, MD, Saint Louis, MO femoral component loosening (2), MCL disruption (1), and
(e – Smith and Nephew) bearing dislocation (2). This rate of revision is higher than
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) reported in literature. Our experience is less impressive than
James J Purtill, MD, Philadelphia, PA (n) commonly cited publications, but more closely approximates
the experience reported in several national total joint registries.
Peter F Sharkey, MD, Philadelphia, PA (e – Stryker)
Surgeons can expect an increased early revision rate compared to
Abstract: Intraoperative tissue or fluid culture remains the gold total knee replacement and must balance this risk with other
standard in diagnosing periprosthetic infection (PPI). However, criteria in choosing this surgical alternative.
an organism is not always isolated from intraoperative cultures.
This study examined if preoperative antibiotics prevented isola- POSTER NO. P125
tion of organisms from intraoperative tissue samples. A total of
171 total knee arthroplasty patients diagnosed with PPI during The Role of Estrogen in Osteoarthritis: Is it
2000-2005 from three referral centers were included in the study. Chondroprotective or Chondrodestructive?
All patients had a positive preoperative aspiration culture and the Vipul Patel, MD, New York, NY (n)
infecting organism(s) was isolated. The details of any antibiotics Bantoo Sehgal, MD, New Hyde Park, NY (n)
that were given to the patients preoperatively were documented.
Alexander Sankin, MS (n)
The sensitivity of the organism to the administered antibiotic was
Chanju Liu, PhD, New York, NY (n)
determined using the antibiogram. Diagnosis of PPI was made
based on 3 out of the following 5 criteria being present: Sally R Frenkel, PhD, New York, NY (n)
abnormal serology (ESR >30mm/hr and CRP >1mg/dL), puru- Paul E Di Cesare, MD, New York, NY (n)
lence at the time of surgical intervention, fluid cell count >1700 Abstract: The role of estrogen in chondrocyte metabolism is
cells/µl; PMN% >65%, positive preoperative aspiration culture, poorly understood. The prevalence of OA is higher in men than
and positive intraoperative culture. 72 out of 171 patients women until the age of 50, but the incidence increases in post-
received preoperative antibiotics prior to surgery. 85% of organ- menopausal women. Therefore, it has been suggested that
isms were sensitive to the administered antibiotic, while 4% of estrogen may be chondroprotective. The purpose of this study

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

the organisms were resistant to the antibiotic and in 11% of the was to define the effects of estrogen on a human cartilage organ
cases the sensitivity was not known as the antibiotic was not part culture in vitro. Articular cartilage specimens obtained from
of the antibiogram. Intraoperative culture was negative in 9 out menopausal women undergoing total knee arthroplasty were
of 72 patients who received antibiotics corresponding to a false incubated under physiologic conditions and treated with various
negative rate of 12.5 %. In contrast, an organism could not be concentrations of estrogen and/or raloxifene. Gene expression of
isolated from intraoperative samples in 8 out of 99 patients who anabolic (Collagen II, Aggrecan and COMP) and catabolic (IL-
did not receive preoperative antibiotics, corresponding to a false- 1b and MMP-13) molecules was then determined using realtime
negative rate of 8%. Chi-square analysis revealed no significant PCR and data was interpreted using multivariate analysis
difference in the incidence of false-negative cultures between the (ANOVA). Physiologic concentration of estrogen treatment
two groups (p=0.34). Administration of preoperative antibiotics resulted in approximately 80%, 95% and 70% increases in the
to patients with positive preoperative joint aspirate does not seem expressions of collagen II, aggrecan, and COMP respectively (P <
to interfere with the isolation of the infecting organism from 0.05). Raloxifene treatment resulted in an 85% and 115%
intraoperative culture samples. Withholding antibiotics from increase in the gene expression for collagen II and aggrecan (P <
patients with an isolated organism does not yield additional 0.05); and a 20% upregulation of the COMP gene. For the cata-
information and can potentially be harmful. bolic molecules, estrogen caused a milder but not statistically
significant increase of IL-1² and MMP-13 (36.6% and 35.9%
POSTER NO. P124 respectively). Raloxifene had a negligible effect (2.8%) on the
Initial Experience with First 500 Oxford Knee expression of IL-1², but resulted in approximately 20% repres-
sion of the expression of MMP-13 gene. The data revealed that
Arthroplasties physiological levels of estrogen and raloxifene significantly
Geoffrey Francis Dervin, MD, Ottawa, Canada (n) increased the cartilage expression of anabolic molecules
Anna Conway, MSc (n) (Collagen II, Aggrecan and COMP) and had no significant
Abstract: Resurgence in mobile bearing unicompartmental effects on the expression of catabolic molecules (IL-1² and MMP-
arthroplasty of the knee has been attributed to the popularity of 13). These findings suggest that estrogen is chondroprotective
minimally invasive surgery, improved instrumentation, and and may be of potential therapeutic value.
encouraging outcome results from the developers and others. A
prospective study was undertaken at an academic institution to
evaluate the initial experience with the first 500 Oxford knees.
The first 500 consecutive Oxford unicompartmental knees
implanted for medial OA of the knee at our institution between

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
451
PPSE 07:Layout 1 1/12/07 1:41 PM Page 452

POSTER NO. P126 Radiographically the mean global limb mechanical axis was
Clinical Study of Coxitis Knee 175° (171°to 180°). The results of this study are encouraging
for the use of UKA when the AVN is limited to one compartment
Shuya Ide, MD, Saga, Japan (n) of the knee and the anterior cruciate ligament is present. In this
Junji Itoh, MD (n) group the condylar bone defect related to the AVN had no nega-
Satomi Nagamine, MD (n) tive effect on the long term fixation of the femoral component.
Elsayed Said, MMC (n)
Masaaki Mawatari, PhD (n) POSTER NO. P128
Takao Hotokebuchi, MD, Fukuoka, Japan (n) Total Knee Arthroplasty Utilizing Cementless Keels
Abstract: It is known that sever osteoarthritis(OA) of the hip And Cemented Tibal Trays: Ten Year Results
leads to secondary OA of the knee. We studied the bilateral lower
Frank R. Kolisek, MD, Indianapolis, IN
leg alignment of 210 patients who underwent total hip arthro-
plasty morphologically and etiologically. The mean age was (a, c, e – Stryker Orthopaedics)
62.9years(from38to85years).We evaluated the femorotibial Eric A Monesmith, MD, Indianapolis, IN
angle(FTA), the leg length discrepancy(LLD) and patellar rota- (e – Stryker Orthopaedics)
tional ratio of substituting the hip rotational position. We found Nennette Jessup, Indianapolis, IN (n)
that the ipsilateral knee (short side of lower extremity) was in Kenneth Davis, MS, Indianapolis, IN (n)
valgus position in 80 patients(38.1%) and in varus position in Thorsten M Seyler, MD, Baltimore, MD (n)
46 patients(21.6%). While the opposite knee (long side of the Michael A Mont, MD, Baltimore, MD
lower extremity) was in valgus position in 62 patients(29.5%) (e – Stryker Orthopaedics, Wright Medical Technology)
and in varus position in 79 patients(37.6%). The main FTA of
Abstract: The problem of early mechanical stability and late
the ipsilateral side was 175.1 degrees. The mean FTA of the
biological osseointegration of the tibial component is a
opposite side was 164.4 degrees. In patients who had LLD more
frequently debated topic in total knee arthroplasty. However,
than 20 mm(85 patients), valgus knee was encountered in 39
solid tibial tray fixation is crucial to avoid the risk of failure due
patients(45.9%). In patients who had adduction contracture of
to the high torque stresses at the bone-prosthesis interface. To
hip less than -5 degrees(87 patients), valgus knee was encoun-
overcome this problem the use of additional devices such as
tered in 44 patients(50.6%).In patients who had patellar
screws, pegs, or keels have been utilized on the tibial compo-
external rotational ratio more than 15% , varus knee was
nent. The purpose of the present study was to assess the results
encountered in 97 patients(30.8%). The rate of valgus knee in
of a total knee arthroplasty system utilizing a cementless keel
coxitits knee was obviously higher than that in primary OA of
and proximally cemented tibial tray. The investigators reviewed
the knee. There was a tendency to develop lateral compartment
the operative reports, medical charts, and postoperative radi-
OA of the knee in the short leg side with severe LLD and adduc-
ographs of 42 consecutive patients (51 knees) who underwent
tion contracture of the hip and medial compartment OA of the
total knee arthroplasty using a knee arthroplasty system that had
knee in the long leg side with severe LLD and external rotational
cementless keels and proximally cemented tibial trays. There
contracture of the hip.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

were 20 men and 22 women who had a mean BMI of 31 (range,

POSTER NO. P127 21-46). Outcome measures included the Knee Society objective
and functional scores, radiographic evaluation, need for revision
A 3-to-15-Year Followup Study of surgery, and Kaplan-Meier- Survivorship analysis. At a mean
Unicompartmental Knee Arthroplasty for Avascular follow-up of 10 years (range, 7-13 years), there was one revision
Osteonecrosis and one radiographic failure as demonstrated by progressive
tibial component radiolucencies. The mean preoperative Knee
Jean-Noel A Argenson, MD, Marseille, France Society objective score improved from 44 points (range, 23-70
(a, c – Zimmer) points) to 93 points (range, 59-100 points) postoperatively. The
Sebastian Parratte, MD, Marseille, France (a – Zimmer) mean functional score improved from 52 points (range, 45-80
Julien Dumas, MD (a – Zimmer) points) to 74 points (range, 0-100 points) postoperatively. The
Jean-Manuel Aubaniac, MD, Marseille, France (a – Zimmer) mean range of motion was 116 degrees (range, 100-125 degrees).
Abstract: The surgical treatment of avascular osteonecrosis The post-operative prosthetic alignment averaged less than 1
(AVN) of the knee is controversial including debridment, degree deviation from the mechanical axis, which may have
osteotomy and arthroplasty. The goal of the study was to eval- contributed to the excellent results in the study population. The
uate the long term results of unicompartmental knee arthro- findings of the present study demonstrate excellent mid-term
plasty (UKA) for AVN. A group of 31 cemented UKA implanted clinical results using a proximally cemented tibial tray with a
in 30 patients with AVN was evaluated after a mean followup of tibial keel design that can be inserted in a press-fit manner. The
86 months (36 to 194 months). Twenty patients were women authors are encouraged by these promising results and await
and ten men, the mean patient age was 71 years (51 to 88 years). further long-term follow-up to see if these results are main-
The etiologies of the AVN included: 6 traumas, 3 steroid- tained.
induced, 1 osteochondritis, and 20 idiopathic. There were 29
medial UKA and 2 lateral. When the necrotic bone was not
removed entirely by the bone cuts the gap was filled by cancel-
lous bone autograft or cement. The knee flexion angle averaged
115° (95° to 130°) preoperatively and 139° (115° to 150°)
postoperatively. The mean Knee Society function score was 50
points (33 to 65) preoperatively and 98 points (85 to 100) at
followup. One knee was revised at 30 months for aseptic loos-
ening. The Kaplan-Meier survivorship was 96.7% at 12 years.

452 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 453

POSTER NO. P129 POSTER NO. P130

Total Knee Arthroplasty in High Activity Patients: Unicompartmental Knee Arthroplasty: Implant
A Comparison to a Low Activity Group Survival and Risk Factors at 11-year Follow-up
Michael A Mont, MD, Baltimore, MD Peter M Bonutti, MD, Effingham, IL
(a, e – Stryker Orthopaedics) (e – Stryker Howmedica)
David R Marker, BS, Baltimore, MD (n) Thorsten M Seyler, MD, Baltimore, MD (n)
Lynne C Jones, PhD, Baltimore, MD Margot McMahon, RN, Effingham, IL (n)
(a – Stryker Orthopaedics) David R Marker, BS, Baltimore, MD (n)
Noah Gordon, BS (n) Michael A Mont, MD, Baltimore, MD
David S Hungerford, MD, Baltimore, MD (e – Stryker Howmedica)
(a, e – Stryker Orthopaedics) Abstract: Although recent advances in implant design and mini-
Abstract: With improvements in prosthetic design and increased mally invasive surgical techniques for unicompartmental knee
patient demand to return to active lifestyles, the use of total knee arthroplasty (UKA) have led to improved clinical results, there
arthroplasties has evolved from simply serving as a pain- continues to be controversy over the effectiveness of this surgical
relieving procedure to one in which optimal function and procedure. Orthopaedic surgeons have proposed specific patient
mobility are the desired outcomes. For many patients, pursuing selection criteria to ensure excellent short and mid-term results;
an active lifestyle frequently includes participation in low to however, there is disagreement as to what are the absolute and
moderate rather than high impact sports. The purpose of this relative contraindications for this procedure. The purpose of the
study was to evaluate the outcome of total knee arthroplasties in present study was to report on the long-term results associated
patients returning to athletic activities by comparing their clin- with the Zimmer UKA implant and to identify factors predictive
ical and radiographic results to a matched group of total knee for failure. Between January 1994 and October 2002, 79 patients
arthroplasties performed in low activity individuals. Using an (101 knees) received a UKA with the Zimmer implant. This cohort
objective post-operative questionnaire, total knee arthroplasty consisted of 32 men and 47 women who had a mean age of 84
patients were initially screened as potential high activity candi- years (range, 47 to 95 years). Patients were followed for a mean of
dates based on their self description as being physically active. eleven years (range, 4 -12 years), and were evaluated using the
After analyzing the type and frequency of each of the patient’s Knee Society clinical and radiographical rating system. There was
activities using a weighted scale formulated from historical Knee a 92% survivorship at final follow-up, with eight knees (6 female
Society activity recommendations, fifty-seven patients (seventy- and 2 male) being revised to a total knee arthroplasty. The mean
two knees) were selected as the high activity cohort. These age of the patients receiving a revision was 68 years (range, 55 to
patients were then matched to a group of low activity total knee 81 years) which was younger than the rest of the cohort (mean age,
arthroplasty patients. Patients from both groups were evaluated 88 years). Four (50%) of the revisions were in patients with avas-
clinically and radiographically at a mean seven-year follow-up. cular necrosis and four (50%) of the revisions were in obese
High activity patients fared as well as their low activity counter- patients (BMI > 30). In addition to these revisions, two patients

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

parts with no significant differences in clinical and radiograph- exhibited advanced tibial polyethylene wear, and another two
ical outcomes. At the time of final follow-up, mean Knee Society patients showed progressive tibial radiolucencies. Based on these
objective scores were 95 points (range, 70-100 points) and 96 results, UKA is a viable option for providing excellent pain relief
points (range, 80-100 points) and mean knee function scores and restoration of function at mid- to long-term follow-up.
were 96 points (range, 80-100 points) and 94 points (range 80- However, these results suggest that obesity and avascular necrosis
100 points) for the high activity and low activity groups, respec- can be detrimental to implant survivorship and should be consid-
tively. The high activity group had one clinical failure, and ered when selecting potential candidates for UKA.
neither group had any revisions. Based on objective survey
results, both cohorts reported high satisfaction; high activity POSTER NO. P131
patients scored a mean of 9.3 on a ten point scale and low Hemicallotasis Open-Wedge Osteotomy for Varus
activity patients reported a mean of 9.1. Although radiolucencies
Osteoarthritis of the Knee
were observed in both the high activity and low activity groups,
none were found to be progressive. These results suggest that Andrea Baldini, MD, Prato, Italy (n)
frequent, moderate level athletic activity had no effect on the Alfredo Trinci, MD, Postola, Italy (n)
outcome of total knee arthroplasty at mid-term follow-up (mean Abstract: Opening wedge high tibial osteotomy (HTO) for varus
of seven years). While the authors await long term results, these knee osteoarthritis has shown several advantages over the classic
findings address patients’ desire to participate in athletic activity closing wedge technique. The use of an external fixator device for
and support the allowance of sustained and frequent participa- medial opening wedge HTO is an alternative to obtain a progres-
tion in low to moderate impact exercise in these patients. sive and precise correction. The aim of the current prospective
study was to evaluate mid-term clinical and radiographic results,
as well as complications, of medial opening wedge osteotomy
using the hemicallotasis technique Forty-nine high tibial
osteotomies were performed for unilateral varus primary
osteoarthritis from 1999 to 2002. A medial incomplete
osteotomy was performed after elevating the superficial collat-
eral ligament. Four pins were inserted, two hydroxyapatite-
coated in the metaphyseal bone, and two standard conical pins
in the diaphyseal bone. The correction started 4 to 5 days post-
operatively. The patient managed the correction by adjusting
half of a turn twice each day. When the desired correction was
achieved, the device was locked. Eight-to-nine weeks after

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
453
PPSE 07:Layout 1 1/12/07 1:41 PM Page 454

surgery, the radiographic healing was evaluated, and if adequate, of the osteotomy; this was not associated with a poor knee score
the device was removed on a outpatient basis. The mean age of or to any adverse clinical findings. In this series TTO performed
the patients was 57 years (range, 32-70 years). The mean follow- to enhance surgical exposure did not adversely affect the outcome
up was 5 years (range, 4-7 years). The mean hip-knee-ankle angle following total knee arthroplasty but resulted in serious compli-
(HKA) was 167 (range 164-171) deg preoperatively and 182 cation in 5% of patients.
(range, 176-186) deg at follow up. We did not observe any early
or late collapse of the new bone wedge. Union was achieved in POSTER NO. P133
all patients, and the mean time to fixation was 69 (range 60-85) What Limits Kneeling After TKA?
days. Knee Society score improved from 52 points preoperatively
Michael A Conditt, PhD, Houston, TX (a – Zimmer)
to 93 at follow up. Eighty-five percent of the patients showed
excellent-to-good clinical outcome. None of the knees had
Heidi Hullinger, BS, Houston, TX (n)
required revision surgery at follow-up. No meta-diaphyseal Sabir Ismaily, BS, Houston, TX (a – Zimmer)
mismatch was noted on both the sagittal and coronal plain at Nikhil Kulkarni, MS, Houston, TX (a – Zimmer)
radiographic analysis. Patellar height (IS ratio) reduced, on Brandon N Devers, BA (n)
average, from 1.1 (±0.4) to 0.9 (±0.4), but no patella was found Daniel T Le, BA, Houston, TX (n)
to be baja. Complications included a number of superficial Philip C Noble, PhD, Houston, TX (a – Zimmer)
infection uneventfully healed such as two cellulitis with Brian S Parsley, MD, Houston, TX (n)
erysipelas-like rushes, and five minor (grade I-II) pin tract infec- Abstract: After TKA, many patients report discomfort during
tions. There were two technical problems. One obese patient kneeling, though little is known about its location or etiology. In
developed an undisplaced intercondylar fracture of the proximal this study, we investigate the intensity and anatomic origin of
tibial osteotomized fragment, which subsequently healed and discomfort during kneeling in TKA patients and normal controls
the patient achieved a good clinical outcome. In another patient to determine the effect of TKA on the discomfort experienced.
the anterior pin on the metaphyseal fragment was positioned Nine total knee patients at least one year post-op (avg. age: 62±8
too anteriorly, and was thereafter repositioned. There were no yrs) and nine age-matched controls (avg. age: 64±10 yrs) with no
neurologic or vascular complications. Using the hemicallotasis knee pathology knelt with their foot and ankle in three different
technique for HTO the authors obtained a precise correction positions. A pain questionnaire combining two previously vali-
with a relatively low complication rate. The use of an external dated surveys was administered after each kneeling sequence.
fixator allowed quick surgery, early weight-bearing, immediate Subjects were asked to assess the severity of any discomfort expe-
knee motion, avoiding permanent hardware on bone. rienced during kneeling, and to identify the location of symp-
Conversion to a total knee arthroplasty seems to be easy when toms on the surface of the skin and deep within the joint. A
this technique has been employed, but the influence of pin tract majority of TKA patients and their age-matched peers experience
infection on possible septic failures remains to be determined. discomfort during kneeling, both on the surface of the skin (TKA:
83%, normal: 67%, p=0.45) and within the joint (TKA: 50%,
POSTER NO. P132
normal: 44%, p=0.67). Kinematically, the terminal flexion angle
Tibial Tubercle Osteotomy in Total Knee reached at the end of the kneeling sequence for TKA patients
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Arthroplasty Surgery (119±10°) was significantly lower than for normals (145±11°,
p<0.001). Pain in the back of the knee was reported as the reason
Claire F Young, FRCS, MBBS, Newcastle Upon Tyne,
for terminating flexion in 42% of TKA patients compared to 11%
United Kingdom (n)
of normals (p=0.01). Older individuals find kneeling uncom-
Robert Barry Bourne, MD, London, ON Canada fortable, regardless of the presence of a total knee replacement.
(a, e – Smith & Nephew, a – DePuy) However, the ability to fully kneel is significantly limited
Cecil H Rorabeck, MD, London, ON Canada (n) following TKA, primarily due to pain localized in the popliteal
Abstract: Tibial Tubercle osteotomy (TTO) is a recognized tech- space. This is most likely due to impingement of soft tissue
nique for improving exposure when performing total knee between the femoral component and the posterior edge of the
arthroplasty (TKR) surgery. We reviewed the patients who had tibial insert. Clearly advances in implant design and kinematics
had a TTO as part of the exposure for their TKR to assess improve- are necessary to replicate knee kinematics at higher flexion angles
ment in Knee Society knee Score (KSS), presence of extensor lag, and alleviate the discomfort associated with kneeling.
TTO union and any complications associated with the procedure.
Forty-two patients (23 female, 19 male) were identified having POSTER NO. P134
had a TTO. All patients had stemmed tibial components The Surgeons’ Revision Burden: Analysis of
implanted. All osteotomies were fixed using Luque wires. Clinical
data collected prospectively and entered in an arthroplasty data-
Caseload Disparities in the United States (1990 to
base was analysed. Standardised standing anteroposterior and 2003)
lateral radiographs taken immediately postoperatively, at 6 and Steven M Kurtz, PhD, Philadelphia, PA (n)
12 weeks, 6 months, 1 year and latest follow-up were also Kevin Ong, PhD, Philadelphia, PA (n)
reviewed. Mean follow-up was 8 years (St Dev ± 2.84, range 2-13 Jordana K Schmier, MA, Alexandria, VA (n)
years). Preoperatively mean extension was -8 ± 14.5°, mean
Fionna Mowat, PhD, Menlo Park, CA (n)
flexion 74 ± 30°, KSS 36.5 ± 20.9. At latest follow-up mean exten-
sion was 4.3 ± 15.3, mean flexion 91 ± 22.2 and KSS 77.9 ± 20.5
Edmund Lau, MS, Philadelphia, PA (n)
(pd0.0001). 73% of patients had an excellent/good score at latest Abstract: It is unclear if the growth in orthopaedic surgeon popu-
follow-up. 25% of patients experienced no extensor lag, of those lation is sufficient to keep pace with significant increase in
patients who had a post-operative lag 66% had resolved within 6 volume of revision hip and knee arthroplasty procedures in the
months of surgery. Mean time for osteotomy union was 14 U.S. We analysed the productivity of hip and knee arthroplasty
weeks. One patient required further surgery for a TTO non-union, surgeons in the U.S. between 1990 and 2003 to evaluate
18% of patients had radiological evidence of proximal migration temporal changes in revision caseload. Nationwide Inpatient

454 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 455

Sample (1990-2003) was used to quantify arthroplasty proce- POSTER NO. P136
dures and surgeons performing primary and revision proce- Arthroplasty in Patients Ninety Years of Age and
dures. 10,000 or more arthroplasty surgeons were typically
captured per year in the NIS using unique, non-identifiable Older
physician IDs. Trends in surgeon caseload were evaluated by Daniel Alfonso, MD, New York, NY (n)
hospital size and hospital type (rural vs. urban, teaching vs. non- Paul E DiCesare, MD, Sacramento, CA (n)
teaching facilities). The average caseload was 3.3 and 2.9 revision Ronald D Howell, BA (n)
hips and revision knees per surgeon/year, respectively. The Piotr Kozlowski, Lodz, Poland (n)
average THA and TKA revision caseload increased slightly over
Abstract: With each decade more individuals live longer
time, at a rate of 0.7 and 0.6 cases/surgeon/decade, respectively.
healthier lives and more patients are seeking total joint arthro-
However, this increase was disproportionately borne by the most
plasty at older ages. The outcomes of 25 patients 90 years of age
productive 5% of revision surgeons. Average revision caseloads
or older who received a total hip or knee arthroplasty at a single
were two to five times higher in large urban teaching hospitals
institution were reviewed. A search of the Hospital for Joint
than in small rural hospitals. Significant differences were
Diseases surgical log books between January 1, 1998, to
observed in surgeon caseload as a function of hospital bed size
December 31, 2004 was done to find all patients older than 90
and hospital type. This novel study documents disparities in the
years of age with total hip and knee replacements. A retrospec-
revision caseload over time and as a function of hospital setting.
tive review of their charts was performed to determine demo-
Because the highest volume surgeons typically have the lowest
graphic and perioperative date. Social Security Death Index and
complication rates, the disparities in revision caseload observed
telephone call surveillance were used to determine if and when
at urban teaching hospitals are consistent with referral from
the patients died and determine surviving patients’ current
outside institutions.
status. Surgical complications included one infected total hip
arthroplasty and one case of prolonged wound drainage; at least
POSTER NO. P135
one medical complication occurred in 56% of the patients,
In Vivo Comparison of PCR vs. PS High Flexion TKA including one postoperative death. At mean follow-up of 4.1
Kinematics years patients were experiencing both pain reduction and higher
Harold E Cates Jr, MD, Knoxville, TN (b, e – Zimmer) functional capacity, but the reported pain reduction was more
substantial than the gains in functional capacity. Analysis of
Richard D Komistek, PhD, Knoxville, TN (a, e – Zimmer)
survival revealed that patients undergoing total hip or knee
Mohamed Mahfouz, PhD, Knoxville, TN (a, e – Zimmer) replacement had slightly better survival characteristics than age-
Sumesh M Zingde, BS, Knoxville, TN (a – Zimmer) matched controls. Patients 90 years of age and older undergoing
Abstract: Though fluoroscopy has previously been used to total hip and knee arthroplasty should be told that they have a
analyze various maneuvers, TKA designed for deep flexion higher likelihood of perioperative medical complications than
maneuvers have not been analyzed. Therefore, the objective of younger individuals, but they can expect pain relief and equal or
this study was to determine and compare the in vivo kinematics better survival than their age-matched peers.
for subjects implanted with either a fixed PS or fixed CR high

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

flexion TKA from full extension to maximum knee flexion. 3D POSTER NO. P137
femorotibial contact positions for thirty subjects (15 PS and 15 Unicompartmental Knee Arthroplasty Compare
PCR), implanted by a single surgeon, were evaluated using fluo-
roscopy. All subjects had postop HSS scores of at least 90. On Favourably to TKA in the Same Patient
average, the subjects demonstrated 117 and 112 degrees of David F. Dalury, MD, Baltimore, MD (a – DePuy)
weight bearing range of motion for the CR high flexion and PS David A Fisher, MD, Indianapolis, IN (a – DePuy)
high flexion TKAs, respectively. Posterior femoral rollback (PFR) Ricardo Gonzales, MD, Hopkinton, NH (n)
of the lateral condyle occurred in 93% of CR and in all of the PS Mary Jo Adams, BSN, Pylesville, MD (a – DePuy)
TKAs. From full extension to maximum flexion, the lateral Melanie R Watts, ATC-L, Indianapolis, IN (a – DePuy)
condyles averaged -4.9 and -6.4 mm of PFR for the CR and PS
Abstract: Surgical options for medial compartment disease of the
TKAs, respectively. The medial condyles averaged -1.0 and -4.2
knee include total knee replacement (TKR) and unicondylar
mm of PFR for the CR and PS TKAs, respectively. Normal axial
knee replacements (UKR). Often patients and surgeons have
rotation averaged 4.8 and 2.9 degrees for the CR and PS TKAs
difficulty deciding on which procedure to undertake given the
respectively. Condylar lift-off greater than 1.0 mm was experi-
same radiographic and clinical symptoms. This study reviews
enced by two subjects in each group. This is the first study to
our experience in patients who have a total knee replacement on
evaluate femorotibial knee kinematics for PS and CR high
one side and a unicondylar on the opposite side. Osteoarthritic
flexion TKAs into deep flexion. Both groups in this study experi-
patients were identified from out data base as having a TKR on
enced, on average, normal-type kinematic patterns, along with
one side and a UKR on the other. Preoperative radiographs were
increased weight bearing ranges of motion, compared to previ-
reviewed to confirm that the TKR patients had medial compart-
ously evaluated TKA using fluoroscopy.
ment disease only. Knee society score (KSS), radiographic
analysis and patient preferences were recorded for all patients.
24 patients met the above criteria. Average follow-up was 3 years.
The KSS knee score was 51 preoperatively and 94 at latest follow-
up for the TKA knees. The KSS knee score was 46 preoperatively
and 95 at latest follow-up for the UKA knees. Knee ROM aver-
aged 0 to 125 degrees in the UKR and 0 to 123 in the TKR group.
No implant was loose and there were no progressive radiolu-
cencies in either group. 50% of patients preferred their UKR, no
patients preferred their TKR and 50% had no preference. At
intermediate follow-up, UKRs compare favourably with TKR

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
455
PPSE 07:Layout 1 1/12/07 1:41 PM Page 456

using the same patient as a control. When asked to choose, and CAD data of 4 different tibial components. The simulated
patients preferred their UKR to the TKR in more cases. UKR TKA was performed using these 4 components for all fifty 3D
appears at this junction to be a valid alternative to TKR for digital tibial models so that the component was correctly aligned
surgical management of the knee three-dimensionally according to the standard technique.
Especially, the rotational alignment was strictly determined
POSTER NO. P138 referencing the A-P axis of proximal tibia. The existence of the
Surgical Visibility During Minimally Invasive TKA overhanging of the tibial component and its incidence according
to the regions of the component were examined. There were 18
Performed via The Subvastus Approach knees (36%) in which overhanging of the component was
Daniel T Le, BA, Houston, TX (n) observed by all 4 tibial components and there were only 11
Michael A Conditt, PhD, Houston, TX (a – Zimmer) knees (22%) in which overhanging was not observed by any of
Nikhil Kulkarni, MS, Houston, TX (a – Zimmer) all 4 tibial components. The mean incidence of the overhanging
Sabir Ismaily, BS, Houston, TX (a – Zimmer) was 28% for the postero-lateral region and 10% for the postero-
James M Saucedo, BA (n) medial region. Of all the overhangings observed in this study,
Philip C Noble, PhD, Houston, TX (a – Zimmer) 76% were observed in the postero-lateral region. The results of
this study indicated that there are certain numbers of knees in
Abstract: Minimally invasive TKA has been advocated to reduce
which the overhanging can be occurred mostly in postero-lateral
the post-operative functional deficit and speed recovery. Despite
region when the tibial component was correctly aligned. This
these potential advantages, a limiting factor is the extent to
suggested the modification of the component design.
which the surgeon has adequate visualization of the surgical site.
The purpose of this study was to examine the surgical visibility POSTER NO. P140
of the joint at each step of a TKA procedure, performed via a
smaller incision. Five surgeons implanted a posterior-stabilized Perioperative Testing For Sepsis in Revision Total
TKA through a 10cm subvastus capsular incision in 5 fresh Knee Arthroplasty
cadavers. All procedures were performed with specialized instru- Craig J Della Valle, MD, Chicago, IL
ments designed for minimally-invasive TKA. At key stages of
(a, b, e – Zimmer, b – Orthobiotech)
each procedure, the openings of the surgical site were measured
Scott M Sporer, MD, Wheaton, IL (a, b, e – Zimmer)
in both the proximo-distal and medio-lateral directions with
each knee in 0, 30, 60 and 90 degrees of flexion. A constant force Joshua J Jacobs, MD, Chicago, IL (a, b, e – Zimmer,
of 40N was applied to standard retractors placed medially and a, e – Medtronic, Spinal Mortion, Arcus, e – Istois)
laterally in the incision. After initial exposure, greater than 95% Richard A Berger, MD, Chicago, IL (a, b, c, e – Zimmer)
of the mediolateral width of the femur was visible at 0, 30 and Aaron Glen Rosenberg, MD, Chicago, IL
60 degrees of flexion. In 90 degrees of flexion, mediolateral visi- (a, b, c, d, e – Zimmer)
bility dropped to an average of 91%. After the distal femoral cut Wayne Gregory Paprosky, MD, Winfield, IL
and after the tibial cut, full (100%) mediolateral visibility was (a, b, c, d, e – Zimmer)
achieved at all four flexion angles. After the distal cut, the visible
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Abstract: While there are multiple tests available for determining

area increased by an average of 7%, 9%, 11% and 13%, at 0, 30,
the presence of infection at the site of a total knee arthroplasty
60 and 90 degrees of flexion respectively. Mediolateral visibility
(TKA), few studies have applied a consistent algorithm to deter-
of the femur and tibia is maintained throughout minimally-
mine the utility of the various tests available. The purpose of this
invasive knee replacement procedures performed via the sub-
study was to evaluate the utility of commonly available tests for
vastus approach; however, the visible area is reduced when the
determining periprosthetic infection. One hundred five consec-
knee is in flexion, particularly early in the procedure. While visi-
utive knees were evaluated by a single surgeon for the presence
bility is adequate with a smaller incision, care should be taken
of infection and underwent reoperation. All patients were evalu-
in visualizing posterior structures.
ated using a consistent algorithm with the following considered
as consistent with infection; ESR>30mm/hr, CRP >10mg/dl,
POSTER NO. P139
synovial fluid cell count >3,000, synovial fluid polymorphonu-
Do the Shapes of Modern Tibial Components Really clear (PMN) differential >65% and frozen section >10PMN per
Match to the Asian Proximal Tibia? high-powered field. Sensitivity, specificity, negative predictive
Takashi Sato, MD, Niigata City, Niigata, Japan value (NPV), positive predictive value (PPV) and accuracy were
determined. Cases were considered infected if two of the
(e – Wright Medical Technology, DePuy Trauma)
following three criteria were met: positive intra-operative
Yoshio Koga, MD, Niigata City, Japan (n) cultures, gross purulence was found at the time of reoperation or
Go Omori, MD, Niigata City, Japan (n) positive histopathology. Eleven cases were excluded (four had a
Satoshi Watanabe, MD, Niigata City, Japan (n) draining sinus, no fluid was obtained from the aspiration in
Tetsuo Hotta, MD, Niigata City, Japan (n) three, the aspirated fluid could not be analyzed in two and
Morio Ichimura, RF, Niigata City, Japan (n) incomplete data was present in two) leaving 94 knees with full
Kou Kai, RF, Niigata City, Japan (n) data for evaluation. Forty-one cases were judged to be infected.
Norio Seitoku, PhD, Tokyo, Japan (n) The synovial fluid cell count had the highest sensitivity (100%),
Abstract: In total knee arthroplasty (TKA), surgeons are some- specificity (98%), PPV (97.6%), NPV (100%) and accuracy
times limited to change the size of the tibial component or (98.9%). Synovial fluid cell count is the most useful periopera-
change the rotational alignment slightly to avoid overhanging. tive testing modality for determining the presence of peripros-
We investigated if the shapes of modern tibial components really thetic sepsis at the site of a TKA.
match to the shapes of Asian tibia. Fifty Asian OA knees that
were planned to receive TKA were analyzed by the computer
simulation technique using their 3D digital CT models of tibia,

456 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 457

POSTER NO. P141 two different time points. The first analysis of alignment param-
Biomechanical Comparison of 1-Pole vs 3-Pole eters compared 35 conventional TKAs with 27 CA-TKAs which
were consecutive computer assisted after 10 initial cases. The
Polyethylene Patellar Implant on Fracture second prospective, randomized study compared 33 conven-
Resistance tional and 33 CA-TKAs using the same implant (Emotion,
Terry A Clyburn, MD, Houston, TX Aesculap) in osteoarthritic patients with bilateral knee ailments
(a – Wright Medical, a, b – Biomet) warranting TKA. The first analysis revealed that the CA-TKA
group had better alignment parameters than the conventional
Volkan B Guzel, MD, Houston, TX (a – Wright Medical)
group. The mean coronal tibiofemoral angle (TFA) was 4.8o in
Kamran Aurang, MD, Laguna Niguel, CA the conventional group and 7.6 o (p = 0.001). The average
(a – Wright Medical) mechanical axis deviation (MAD, normal: 0.4 ‘ 0.6) was 0.35 in
Catherine G Ambrose, PhD, Houston, TX the conventional group and 0.49 (p = 0.000). The second
(a – Wright Medical) analysis showed no significant differences between the conven-
Abstract: The purpose of this study was to compare the effects of tional and CA groups in any alignment parameters. The mean
a 1-peg versus 3-peg patellar component on fracture of the resur- TFA was 7.58 in the conventional group and 6.6 (p = 0.25). The
faced patella, and evaluate the effect of osteoporosis on these average MAD in the convential and CA groups was 0.49 and
findings. Twenty-nine matched pairs of cadaveric patella were 0.47, respectively (p = 0.48). CA-TKA group had a trend to less
randomly resurfaced with either 1-peg or 3-peg polyethylene posterior slope than the conventional group (2.6o vs 3.9o, p =
implant. Five non-resurfaced cadaveric patella were used as 0.08). No significant differences were found in any parameters
controls. Bone mineral density was measured using DEXA scan- between the CA-groups in the first and second analyses (p >
ning prior to resurfacing. Specimens were placed over a femoral 0.05). The absence of significant differences between the two
component beneath a drop tube apparatus. The extensor mech- groups in the second series was interpreted stemming from the
anism was secured to freeze clamps with constant, reproducible remarkable improvement in the conventional group of the
tension. Lead weights were released through the drop tube at second series. The finding of no differences between the first and
graduated levels until fracture was achieved, as confirmed with second series in the CA-TKA groups implies that learning curve
fluoroscopy. The energy to fracture for each specimen was calcu- in CA-TKA may not be problematic seriously. This study suggests
lated and analyzed statistically. When the groups were divided that CA-TKA improves the quality of conventional TKA by
into higher versus lower bone mineral density subgroups, there providing the education opportunity for understanding surgical
was a significant decrease at energy to fracture in the 1-peg group principles of TKA.
(p=0.002) whereas the difference was not statistically significant
in the 3-peg group (p=0.126). When the high and low density POSTER NO. P143
patella were combined, the energy to fracture was 326.88 joules Complications with the Mini-Subvastus Total Knee
in 1-peg patella, 297.11 joules in 3-peg patella, and 217.38 joules
in intact patella. There was no statistically significant difference
Arthroplasty; Minimum Two Year Follow-up
in energy to fracture between the groups (p=0.54). Our study William C Schroer, MD, Saint Louis, MO (a, e – Biomet)

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

results showed that 1-peg patella resurfacing was significantly Paul Diesfeld, PA-C, Saint Louis, MO (a – Biomet)
weaker in the lower bone mineral density subgroup. We do Mary E Reedy, RN, Saint Louis, MO (a – Biomet)
recommend the use of 3-peg patellar component resurfacing in Angela LeMarr, RN, Saint Louis, MO (a – Biomet)
patients with lower bone mineral density. Abstract: Concerns exist that limited exposure and longer
surgical time with minimally invasive (MIS) techniques may
POSTER NO. P142 lead to increased complications following total knee arthro-
Educational Effect of Computer Assisted Surgery in plasty (TKA). This study evaluates the complication rate and
Total Knee Arthroplasty need for further surgery in our first 275 mini-subvastus TKA
patients with minimum two year follow-up. All procedures were
Tae Kyun Kim, MD, Seongnam-si, Republic of Korea performed by a single surgeon with the same PS cemented TKA.
(a – Smith & Nephew, b – Braun-Aesculap) Since March 2003, this MIS procedure has been utilized in 99%
Chong Bum Chang, MD, Seongnamsi, Republic of Korea of our primary TKA. Data was collected prospectively.
(a – Smith & Nephew, b – Braun-Aesculap) Complications that lengthened hospital stay, required more
Jae Ho Yoo, MD, Seoul, Seoul, Republic of Korea (n) frequent office visits, or required further surgery were deter-
Heon Jung, MD (n) mined. Two year data was available for 245 patients with a mean
Yeon Gwi Kang, MD, Seongnam-Si, Republic of Korea (n) follow-up of 30 months (range 24-40). Seventeen patients had a
Su Won Yoon, MD, Seongnam-Si, Republic of Korea (n) lengthened hospitalization, eleven for medical and six for knee
specific complications. Thirty patients required additional office
Sun-jin Choi, MD, Busan, Republic of Korea (n)
visits for increased surveillance of surgical wounds. Surgery was
Sang Cheol Seong, MD, Seoul, Republic of Korea (n) not required for wound or hematoma concerns. Two knees
Abstract: Computer assisted total knee arthroplasty (CA-TKA) developed deep infections that required two-stage revision. Two
has been proven to improve the quality of limb and implant knees have been revised due to tibial component failure. Four
alignment of TKA. Another potential advantage of CA-TKA is an patients underwent further knee surgery for other knee compli-
educational benefit that navigational process would improve cations during their first year of follow-up that did not require
our understanding of basic principles of TKA. This study shows knee revision. Seventeen patients (6%) were diagnosed with a
that CA-TKA improves the quality of conventional TKA as well as patella clunk syndrome that required arthroscopic debridement.
that of navigational TKA Of the 138 primary TKAs between Two knees underwent successful closed manipulation at six
October 2004 and September 2005, 70 were carried out with the weeks post-op. Four patients (1.5%) required revision during
technique of CA-TKA (Orthopilot, Aesculap). Comparative the first two years of follow-up: two for infection and two for
analysis between conventional and CA-TKA were performed at tibial component failure. Both knees that developed tibial loos-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
457
PPSE 07:Layout 1 1/12/07 1:41 PM Page 458

ening had a decreased tibio-femoral angle on plain radiographs. study is to evaluate the safety and efficacy of simultaneous
The 6% incidence of patella clunk syndrome is consistent with (consecutive) bilateral revision TKA. From 1998-2004, 56 simul-
reports in the literature and was eliminated with a newly taneous bilateral revision TKA were performed in consecutive
designed femoral component. Excluding the patella clunk fashion under a single anesthetic. The failure modes requiring
patients, 2.9% of our MIS TKA required surgery during the first revision TKA included loosening, instability, stiffness, and wear
two years of follow-up. Overall, the use of the mini-subvastus with osteolysis. Clinical and radiographic results were evaluated
surgical technique did not increase the incidence of complica- by a modified knee society rating system. Careful review of the
tions or develop new modes of TKA failure. operative record and hospital charts was also performed to eval-
uate intraoperative and postoperative cardiopulmonary events
POSTER NO. P144 Follow-up averaged 5.5 years (range 2-8 years). The average
Peri-prosthetic Supracondylar Femur Fractures preoperative knee score was 45 and improved to 90 postopera-
tively. Range of motion improved from 8-85 degrees to 2-115
Following Total Knee Arthroplasty degrees. Tourniquet times averaged 57 minutes (range 37-78
Hari Bezwada, MD, Philadelphia, PA (e – Zimmer) minutes). There were no lasting adverse cardiovascular or
David George Nazarian, MD, Philadelphia, PA thromboembolic complications. However, one transient neuro-
(a, e – Zimmer) logic change occurred that was attributed to fat embolism. Four
Jess H Lonner, MD, Philadelphia, PA (a, e – Zimmer) patients required reoperations for patellofemoral complications,
Robert E. Booth, Jr MD, Philadelphia, PA (a, e – Zimmer) loosening, and recurrent instability. Although the need for
Abstract: Peri-prosthetic supracondylar femur fractures following simultaneous bilateral TKR may be rare. It may be a viable
total knee arthroplasty (TKA) are an infrequent but devastating option in carefully selected patients. As one source of persistent
complication. They may require extensive treatment and leave disability may include a poorly functioning contralateral TKA,
the patients with a less than desirable functional result. The which, when left untreated, may preclude normal motion and
purpose of this study is to review our experience using both function of the operated joint. Thus, the results of revisional
intramedullary fixation and traditional open reduction and knee arthroplasty may be further compromised if a failed
internal fixation techniques for managing this complication. contralateral TKA is not addressed. These results compare favor-
From 1998-2004, 54 supracondylar femur fractures treated at ably with previous reports on bilateral primary knee arthroplasty
our institutions. The time following index arthroplasty ranged without a significant increase in complications.
from 1-15 years. Twenty-eight fractures occurred in prosthetic
POSTER NO. P146
designs that contained an open box that accommodated retro-
grade intramedullary rod fixation (FIMR). 26 fractures required The Use of Computer Navigation to Assess Medial
traditional open reduction with internal fixation (ORIF) because Soft-Tissue Releases in the Knee
of closed boxes or distal fracture patterns. Adjunctive bone
Craig M McAllister, MD, Kirkland, WA
cement was used in two cases to supplement fixation. Post-oper-
(e – Stryker Orthopedics)
ative range of motion, alignment, knee society knee scores, and
complications were recorded. Post-operative follow-up averaged Jeff Stepanian, PA, Kirkland, WA (n)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

5 years (range 2-8). Average range of motion was 5-105 degrees Abstract: Medial soft-tissue releases are done on the tibial side in
for those who underwent FIMR and 5-100 degrees for those with an effort to achieve incremental correction of varus malalign-
ORIF. Residual alignment at last follow-up for FIMR was 4 ment during knee replacement. This study uses computer navi-
degrees of valgus and 5 degrees of valgus for the ORIF group. gation to quantify the impact of sequential soft-tissue releases on
Knee society knee scores were 83 and 85 respectively at latest angular alignment throughout a range of motion. Eight cadaver
follow-up. There were no cases requiring revision arthroplasty. knees were placed in a specially designed mechanical leg. A
Complications included 6 nonunions requiring reoperations. constant valgus force was applied through a range of motion.
Supracondylar femur fractures following TKA remain a chal- Sequential soft-tissue releases were done on the medial side.
lenging and difficult problem. FIMR appears to be the treatment Computer navigation was used to quantify the impact of each
of choice when it is feasible. However, traditional ORIF may also release on angular alignment at 0, 30, 45, 60, and 90 degrees. We
yield satisfactory results in those designs that cannot accommo- saw no significant change in angular alignment with release of
date retrograde FIMR fixation. the deep MCL, posteror oblique ligament, semimembranosus,
and posterior capsule (p less than .01). Only complete release of
POSTER NO. P145 the superficial MCL, PCL, and the gastrocnemius resulted in
significant changes in angular alignment (p less than .01).
Simultaneous Bilateral Total Knee Revision
However, these changes were minimal in extension and marked
Arthroplasty in flexion (p less than .01) This model proved highly accurate for
Hari Bezwada, MD, Philadelphia, PA (e – Zimmer) assessing the impact of soft-tissue releases on angular alignment.
Jess H Lonner, MD, Philadelphia, PA (a, e – Zimmer) Soft-tissue releases on the tibial side did not result in incre-
David George Nazarian, MD, Philadelphia, PA mental changes in angular alignment. Instead, they yielded
(a, e – Zimmer) abrupt changes that affected angular alignment in flexion much
more than in extension. Relying on tibial releases for the severe
Robert E. Booth, Jr MD, Philadelphia, PA (a, e – Zimmer)
varus knee may contribute to significant ligament imbalance.
Abstract: As the number of primary total knee arthroplasties
(TKA) performed continues to increase, so will the number of
obligate number of revision TKA. Occasionally, a patient may
present with significant disability associated with failed bilateral
TKA. This has traditionally been treated as a staged reconstruc-
tion, because of concerns regarding surgical morbidity and
mortality. However, the patient might best functionally benefit
from bilateral simultaneous revision TKA. The purpose of this

458 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 459

POSTER NO. P147 from pre-operative CT measurement, and the angle between SEA
Is There a Functional Benefit to Obtaining High and PCA (Navi-PCA) was examined using a measurement func-
tion of the navigation system. The mean of CT-PCA and Navi-
Flexion After Total Knee Replacement? PCA were 2.01±2.48 degree’mean±SD’and 2.59±3.74
Robert Michael Meneghini, MD, Indianapolis, IN respectively. Strong correlation was observed between these two
(a, e – Zimmer) parameters (P’0.0001) . However, the differences between these
Jeffery L. Pierson, MD, Indianapolis, IN (e – Zimmer) two parameters were more than 2 degrees in 9 of the 31 knees,
Michael E Berend, MD, Mooresville, IN (a, c, e – Biomet) and such discrepancy was more frequently observed in knees
Merrill A Ritter, MD, Indianapolis, IN (a, e – Biomet) with sever patello-femoral osteoarthritis. Intra-operative identifi-
cation of the SEA was reliable, but patello-femoral osteoarthritis
Kenneth Davis, BS, Mooresville, IN (n)
affects the accuracy of it
Mary Ziemba-Davis, Indianapolis, IN (n)
Abstract: There is recent emphasis on developing implant POSTER NO. P149
systems that are designed to accommodate high degrees of knee
flexion after TKR. However, clinical evidence is lacking to
In Vivo Tibial Polyethylene Insert Thickness Losses
support the true functional benefit of high flexion. A retrospec- in One Knee System: Role of Sterilization Method
tive review of 511 total knee replacements in 370 patients was Matthew B Collier, MS, Lafayette, LA
performed. The mean patient age was 67.7 years (range, 34 to (a – Inova Health Systems)
95) at time of surgery and the mean body-mass-index was 33.0 C Anderson Engh Jr, MD, Alexandria, VA (e – DePuy)
(range, 17.9 to 57.4). The mean follow-up was 3.7 years (range, Kyle M Hatten, BS (a – Inova Health Systems)
2 to 8 years). Regression analysis was performed to determine
Stuart D Ginn, Winston Salem, NC
the effect of obtaining high flexion (greater than 125 degrees) on
Knee Society Scores (KSS), and stair, function and pain scores. (a – Inova Health Systems)
340 of 511 TKRs (66.5%) obtained ROM greater than 115 Todd Michael Sheils, MD, Opelika, AL
degrees and 63 (12.3%) TKRs obtained high flexion greater than (a – Inova Health Systems)
125 degrees. There was no difference between the patients who Gerard Anderson Engh, MD, Alexandria, VA (c – DePuy)
obtained greater than 115 degrees and those who obtained high Abstract: Weightbearing anteroposterior radiographs of inserts
flexion greater than 125 degrees in Knee Society Scores (p=0.34), sterilized via different methods afford useful insights into the
function scores (p=.57), and the use of support for ambulation clinical wear performance of polyethylene in the knee. 522
(p=.16). Patients with greater than 125 degrees of flexion are Anatomic Modular Knee primary total knees had: i) a cruciate-
1.56 times more likely to demonstrate optimal stair function retaining or -substituting insert that had been sterilized with a
(p=0.02). Obtaining high flexion greater than 125 degrees after non-radiation gas plasma method (2001-1996) or with gamma
TKR does not offer a benefit in terms of overall knee function. radiation in either an oxygen-free barrier package (1995-1994,
However, obtaining such a high degree of flexion does improve mean dose: 21-34kGy) or ambient air (1993-1987, 28-35kGy),
the patient’s ability to climb stairs optimally. and ii) 5-18 years of radiographic follow-up. Medial compart-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

ment time-adjusted polyethylene thickness losses were assessed
POSTER NO. P148 in 411 knees (where the top surface of the metal tibial baseplate
Efficacy of the Identification of the Epicondylar Axis was within 4° of the ideal flat line projection on the most recent
of however many radiographs satisfied this condition beyond 5
in TKA: An Evaluation Using a Navigation System postoperative years) as the initial insert thickness minus its radi-
Akio Kobayashi, MD, Osaka, Japan (a – DePuy, JMM) ographic thickness (magnification-adjusted distance from
Hiroyoshi Iwaki, MD, Osaka, Japan (a – Zimmer) femoral component medial condyle to transverse axis of base-
Yoshinori Kadoya, MD, Sakai, Japan (a – Biomet) plate top surface), per years of follow-up to the examined radi-
Kentarou Iwakiri, MD, Osaka, Japan (n) ograph. Time-adjusted polyethylene loss was highest with
Yoichi Ohta, MD, Osaka, Japan (n) irradiation-in-air-sterilization (mean ± standard deviation:
Yoshio Tokuhara, MD (n) 0.150±0.166mm/year, maximum:1.088mm/year), least with
Fumiaki Inori, MD, Osaka, Japan (n) irradiation-in-barrier-sterilization (0.019±0.056mm/year,
maximum:0.159mm/year), and of an intermediate magnitude
Kunio Takaoka, MD, Osaka, Japan (n)
with non-radiation-sterilization (0.062±0.070mm/year,
Abstract: Determination of the rotational alignment of the maximum:0.243mm/year). Per multiple regression, irradiated-
femoral component is one of the difficult steps in total knee in-air insert losses increased with shelf age, decreasing patient
arthroplasties (TKA). Surgical epicondylar axis (SEA) is often age, more varus postoperative limb alignment, and cruciate-
used as a land-mark of the femoral rotation because it is an extra- retaining insert geometry (each p<0.01), whereas non-irradiated-
articular structure and less likely affected by the deformation of in-air (irradiated-in-barrier or non-irradiated) insert losses
osteoarthritis. However identification of SEA is occasionally increased with decreasing radiation dose, male gender, and
uncertain. In this study, we examined the efficacy of the intra- increasing weight (each p<0.01). At comparable mean follow-up
operative identification of SEA using a computer-assisted navi- (8 versus 9 years), medial compartment radiographic thickness
gation system as a measurement tool. Thirty-one osteoarthritis losses of irradiated-in-barrier inserts (that were not treated to
knees which underwent TKA were examined. Computed tomog- eliminate free radicals, and thus have some yet-to-be-
raphy of the lower extremity was taken for every patient pre- manifested potential for mechanical fatigue) are nearly an order
operatively, and the angle between SEA and posterior condylar of magnitude less than those of their irradiated-in-air (fatigue-
line (PCL ‘was three-dimensionally measured as CT-posterior prone) predecessors. The irradiated-in-barrier and non-irradi-
condylar angle (CT-PCA) using a 3D measurement software. ated inserts should be followed closely owing to their differing
Then TKA was performed using an image-free computer assisted theoretical susceptibilities to particulate burnishing losses and
navigation system (Vector Vision, BrainLab). During the opera-
tion the SEA was identified manually without any information

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
459
PPSE 07:Layout 1 1/12/07 1:41 PM Page 460

oxidation. Besides reducing polyethylene losses, implementa- Between 1985 & 2000 we identified 208 TKAs performed in 159
tion of these alternative sterilization practices seems to have patients with a minimum 5-year follow-up. Mean follow-up was
redefined why inserts of this design lose thickness in vivo. 8.4 years ± 4.1. There were 65 males and 143 females. Mean age
at surgery was 49 ± 5.3 years. Mean BMI was 33.1 ± 7.3. Thirth-
POSTER NO. P150 two revisions were performed during the study period. Seven revi-
The Cost Effectiveness of Revision Total Knee sions were performed for polyethylene wear, 5 for instability and
3 aseptic loosening. There were 5 septic failures. Five, 10 and 15
Arthroplasty year survival with any revision as end-point was 98, 91.9 and
Alexander Burns, MD, London, Canada (*) 68.1% respectively. No patient factors (gender, diagnosis, pre-
Robert Barry Bourne, MD, London, Canada (*) operative deformity or BMI) or surgical factors (previous surgery,
Steven J MacDonald, MD, London, Canada (*) implant design) significantly influenced outcome. This data
Cecil H Rorabeck, MD, London, Canada (*) demonstrates that TKA even in younger, potentially more active
Bert M Chesworth, PhD (*) patients has survival rates equal to TKA in older patients up to 10
Abstract: The excellent cost effectiveness of total knee arthro- yeras. Survivorship beyond 10 years tailed off and patients require
plasty has beeen well established. We aimed to determine the careful follow-up. We could not identify any factors that predicted
cost effectiveness of revision TKA, a procedure more costly, tech- poorer outcome in this cohort.
nically difficult and associated with higher complication rates.
POSTER NO. P152
Clinical outcomes data from the Ontario Joint Replacement
Registry was obtained for 1493 primary TKA patients and 73 In Vivo Comparison of Kinematics for Subjects
TKAR patients who had a baseline Western Ontario McMaster Having a NexGen High Flex or Scorpio Superflex PS
Arthritis (WOMAC) score at the decision date for surgery and at
1 year follow-up. The Ontario Ministry for Health funding allo-
TKA
cation (2005) for TKA (US$7331) and revision TKA (US$8850) Shinro Takai, MD, Tokyo, Japan (n)
was used to generate a cost per 10 point improvement in Michael C Owens, BS (a – Zimmer)
WOMAC for the 2 procedures. The cost analysis of primary Richard D Komistek, PhD, Knoxville, TN (a – Zimmer)
versus revision TKA was expressed as the cost incurred for each Abstract: The objective of the current study was to determine the
10-point WOMAC score increase. Utilizing this outcome, $1667 in vivo kinematics for subjects implanted with either the
was spent for every 10-point WOMAC score increase for patients Zimmer NexGen High Flex PS TKA (NexGen) or the Osteonics
undergoing a primary TKA compared with $2602 per 10-point Scorpio Superflex PS TKA (Scorpio). In vivo kinematic patterns
increase for patients undergoing a revision TKA. The ratio of cost for 20 subjects, 10 subjects for each TKA design, were determined
per 10-point WOMAC score increase comparing revision TKA to using fluoroscopy while performing a deep knee bend. On
primary TKA was 1.56. Thus, revision TKA was approximately average the subjects having a NexGen implant experienced -5.0
65% as cost effective as a primary TKA. Health economists and -1.3 mm of posterior femoral rollback of the lateral and
consider any intervention which costs less than $20,000 per medial condyle compared to -3.1 and -1.8 mm for the Scorpio
quality adjusted life year (QALY) to have excellent cost effective- implant. All ten subjects having a NexGen TKA experienced
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

ness.While only being 65% as cost effective as primary TKA, revi- normal axial rotation patterns compared to 8/10 Scorpio TKA
sion TKA is still considered a very cost-effective medical subjects. The NexGen TKA subjects experienced an average of
intervention applying the standards used by health economists. 5.0° of axial rotation compared to 2.6° for the Scorpio TKA
subjects. The maximum amount of condylar lift off was 2.1 mm
POSTER NO. P151 for the NexGen TKA compared to 2.5 mm for the Scorpio TKA.
Survival Of Total Knee Replacement Performed In The average amount of weight bearing range-of-motion was
110° for the subjects having a Nexgen TKA compared to 95° for
Patients Aged 55 Or Less
subjects with a Scorpio TKA. Nine of the ten subjects having a
Claire F Young, FRCS, MBBS, Newcastle Upon Tyne, NexGen TKA experienced at least 100° of weight-bearing range-
United Kingdom (n) of-motion compared to 3/10 subjects with a Scorpio TKA. The
Stephen Kearns, MB FRCS(I) (n) NexGen High Flex PS TKA experienced greater posterior femoral
Michael Curtis, MD, London, Canada (n) rollback, more normal axial rotation patterns, less condylar lift-
Doug Naudie, MD, London, Canada off and greater range-of-motion. It is possible that the implant
(a – Smith & Nephew, DePuy) geometry contributed to the differences in these results.
Richard W McCalden, MD, London, Canada
POSTER NO. P153
(a – Smith & Nephew, DePuy)
Steven J MacDonald, MD, London, Canada Knee Wear Analysis Highlights Differences
(a, e – DePuy, a – Smith & Nephew) Between Abrasive Wear and Fatigue Wear
Cecil H Rorabeck, MD, London, Canada (n) John H Currier, MS, Hanover, NH (a – DePuy, Zimmer)
Robert Barry Bourne, MD, London, Canada Ashley E Levack (a – DePuy, Zimmer)
(a, e – Smith & Nephew, a – DePuy) Michael B Mayor, MD, Lebanon, NH
Abstract: To provide a lasting total knee arthroplasty (TKA) for the (a, e – DePuy, a – Zimmer)
young patient with end-stage gonarthrosis remains a major chal- Kimberly A Lyford, BA, Hanover, NH (a – DePuy, Zimmer)
lenge. The concerns relate to the potential increased demands on Ivan M Tomek, MD, Lebanon, NH (n)
the articulation in a more active, younger patient that may trans- Abstract: Wear of knee bearings is frequently cited by clinicians
late into increased rates of wear and aseptic loosening. The as the cause of device failure and revision. Abrasive/adhesive
purpose of this study was to assess the long-term outcome of a wear, such as backside wear of modular knee inserts, is a
large cohort of patients aged 55 or less at the time of TKA and to suspected factor in osteolysis. Cracking and delamination are
assess how patient and surgical factors affect survival rates.

460 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 461

more commonly found on the articular surface of bearings, and combined ACL reconstruction and UKA are excellent. Lack of
can result in large amounts of material removal, often altering pathological radiolucencies and near normal knee kinematics
the kinematic function of the device or causing catastrophic suggest that early tibial loosening due to eccentric loading is
failure. A series of 264 retrieved modular knee inserts of one type unlikely. Similarly, wear is unlikely to be a problem because of
was assessed for all wear modes. Articular and backside wear the wear resistance of mobile bearing devices.
were quantified. Oxidation was measured using FTIR spec-
troscopy. Statistical correlations among retrieval parameters were POSTER NO. P155
investigated using SPSS. Mean articular and backside wear Uncemented Knee Design; Lessons from Retrievals
depths were 0.71 mm and 0.34 mm, respectively. Mean backside
wear volume was 740 cubic millimeters. Osteolysis correlated
and Porous Coating
more strongly to backside wear than to articular wear. Articular John P Collier, DE, Hanover, NH
wear was correlated more strongly with oxidation and with (a, e – DePuy, a – Zimmer)
fatigue modes of cracking and delamination. Abrasive/adhesive Michael B Mayor, MD, Lebanon, NH
wear such as backside wear generates fine debris that can result (a, e – DePuy, a – Zimmer)
in osteolysis. Articular wear may also be abrasive but bearings Douglas Van Citters, MS, Hanover, NH (a – DePuy, Zimmer)
that are oxidized frequently demonstrate contact fatigue damage Kimberly A Lyford, BA, Hanover, NH (a – DePuy, Zimmer)
that produces larger debris, expected to be less bioactive, but that
Nicola M Mootoo, AB (a – DePuy, Zimmer)
can degrade articular geometry and bearing integrity catastroph-
ically. New polyethylenes with improved wear resistance may be Abstract: A number of manufacturers have recently released new,
effective in reducing both backside and articular abrasive/adhe- uncemented knee designs with the expectation of achieving
sive wear. Polyethylene that is produced without radiation or has biological fixation and possibly expanding the acceptable activity
free radicals eliminated should be more resistant to oxidation level beyond that which cemented components offer. There were
and the subsequent fatigue damage in vivo. reasons that many of the first generations of cementless knees
failed and it might be wise to revisit them before repeating them.
POSTER NO. P154 One thousand retrieved, cementless knee components from 11
manufacturers, 134 surgeons and 382 patients were evaluated by
Combined ACL reconstruction & Oxford UKA: one researcher for wear over a 25 year period. Histologies of a
A Clinical, Radiological & Kinematic Review representative sample of the components provided insight into
Hemant G Pandit, FRCS, Oxford, United Kingdom the role of various fixation methods on bone ingrowth. Adequate
(b – Biomet) bone ingrowth was observed in femoral, patellar and tibial
components. Tibial component design was found to be directly
John Anthony Gallagher, MD, Bribie Island, Australia
related to the frequency of ingrowth. Two screws, four screws and
(b – Biomet)
porous coated pegs all resulted in improved fixation. Bone
Bernard van Duren, B Eng (b – Biomet) ingrowth of well fixed femoral and patellar components was
David J Beard, DPhil, Oxford, United Kingdom (b – Biomet) common; ingrowth of tibial components was much more prob-
Harinderjit Singh Gill, PHD, Oxford, United Kingdom lematical. Screws enhanced tibial fixation but screwholes were a

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

(b – Biomet) path for debris leading to osteolysis. Porous coated pegs were as
Andrew Price, FRCS, Victoria, Australia (b – Biomet) effective in improving fixation without providing a path for
Christopher A F Dodd, FRCS, Oxford, United Kingdom debris migration. A tibial component with either a well fixed
(a, b, c – Biomet) polyethylene bearing or a monoblock design or a mobile bearing
component should both minimize debris generation and protect
David W Murray, MD, Oxford, United Kingdom
the tibial surface from debris.
(a, b, c – Biomet)
Abstract: Treatment options for the young active patient with POSTER NO. P156
isolated symptomatic medial compartment OA and pre-existing
ACL deficiency are limited. Implant longevity and activity levels
Cementing Nonmatching Tibial Inserts into Well
may preclude TKA, whilst HTO and UKA are unreliable due to Fixed Baseplates in Revision Total Knee Arthroplasty
ligamentous instability. UKAs in ACLDtend to fail because of Ormonde M. Mahoney, MD, Athens, GA (c, e – Stryker)
tibial loosening possibly resulting from eccentric loading. Tracy Kinsey, RN (a – Stryker)
Combined UKA and ACL reconstruction may therefore be a Abstract: We describe a technique for adapting nonmatching
solution. Fifteen patients with combined ACL reconstruction components in total knee arthroplasty revision (TKAR) cases
and Oxford UKA (ACLR group), were matched (age, gender and where a desired revision femoral component is incompatable
follow-up period) with 15 patients with Oxford UKA with intact with an existing well fixed modular tibial tray. From 1998 to
ACL (ACLI group). Prospectively collected clinical and x-ray data 2003, six TKARs were performed where the femoral revision
from the last follow-up (minimum 3 years, range: 3 - 5) were required a component that was incompatable with an existing
compared. Ten patients from each group also underwent in-vivo well fixed modular tibial tray. In each case a slightly smaller insert
kinematic assessment using a standardised protocol. At the last that did not match the tibial locking mechanism was cemented
follow-up, the clinical outcome for the two groups were similar into the existing tray after widening the posterior cutout of the
(ACLR: OKS 46, KSS (objective): 99, ACLI: OKS 43, KSS (objec- polyethelene with a saw. In a seventh case, a well fixed femur was
tive): 94). One ACLR patient needed revision due to infection. retained and a non-matching tibial insert was cemented into an
Radiological assessment did not show any significant difference incompatable revision tray. Primary posteriorly stabilized inserts
between relative component positions and none of the patients were used in all of the cases. At 41 months average follow-up
had pathological radiolucencies suggestive of component loos- there have been no fixation problems or failures of the tibial
ening. Kinematic assessment showed slight posterior placement inserts. Average extension/flexion at last follow up was 2 to 117
of the femur on tibia in extension for the ACLR group, which deg. with flexion ranges of 105 to 125 deg and good to excellent
corrected with further flexion. The short-term clinical results of knee society scores. One patient underwent a subsequent revision

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
461
PPSE 07:Layout 1 1/12/07 1:41 PM Page 462

due to sepsis five years after the index revision and the tibial insert separation. The average weight-bearing flexion was
was found well fixed in the tray. Cementation of polyethylene 116°(±12.86°), 117°(±9.52°) and 135°(±17.76°) for subjects
inserts into nonmatching acetabular components has undergone having PCR TKA, LPS TKA and normal knee, respectively. In all
widespread use for several years. Bench studies have confirmed the three groups the contact point moved from inferior to the
that the fixation achieved is durable. This report describes the use superior direction; from -2.6(±3.5) mm to 7.2(±2.6) mm, from
of this technique in TKAR which provided durable fixation while -1.1(±4.8) mm to 8.3(±3.8)mm, from -12.2(±3.3) mm to 7.9
avoiding tibial damage that might have occurred needlessly had (±2.6) mm for PCR TKA, LPS TKA and normal knee, respectively.
the implant been extracted. Subjects having either implanted knee experienced similar kine-
matic patterns. Those patterns were also similar to those
POSTER NO. P157 observed in the normal knees, though the range was smaller.
Uncemented Knee Design; Lessons from Retrievals Only subjects having TKA demonstrated patellofemoral separa-
tion. Patellofemoral kinematics and kinetics were similar for
and Polyethylene Oxidation both TKA groups compared to the normal patellofemoral joint,
John P Collier, DE, Hanover, NH leading to the assumption that high flexion TKA will not lead to
(a, e – DePuy, a – Zimmer) detrimental conditions during deep flexion activities.
Michael B Mayor, MD, Lebanon, NH
(a, e – DePuy, a – Zimmer) POSTER NO. P159
Barbara H Currier, MChE, Hanover, NH The Effects of Socioeconomic Status on Patients
(a – DePuy, a – Zimmer) Outcome after Total Knee Arthroplasty
Stephen R Kantor, MD, Lebanon, NH (n) Edward T Davis, FRCS, Brimingham, United Kingdom
Nicola M Mootoo, AB (a – DePuy, a – Zimmer) (b – Stryker)
Abstract: Interest in cementless knee design has recently been Elizabeth Anne Lingard, MD, Newcastle upon Tyne, United
rekindled and a number of new designs have been recently
Kingdom (a – Stryker)
released. Recognition of the mechanisms of failures of early
Emil H Schemitsch, MD, Toronto, Canada (a – Stryker)
cementless knees may be helpful in assessing the new compo-
nents. The modes of failure of nearly a thousand retrieved, James P Waddell, MD, Toronto, Canada (a – Stryker)
cementless knee components were compiled. Metallurgical Abstract: We aimed to identify whether patients in lower socioe-
examination of failed metal components and oxidation studies conomic groups had decreased functional levels prior to Total
of many of the failed polyethylene components along with a Knee Arthroplasty and then establish whether these patients had
failure analysis of each device were carried out. Oxidation poorer post-operative outcomes following total knee arthro-
secondary to radiation sterilization was the most frequent factor plasty. Data was obtained from a prospective observational study
in polyethylene bearing failure. Deformation of patellar compo- of 974 patients undergoing primary Total Knee Arthroplasty for
nents was found to be a key factor in separation of the bearing osteoarthritis. The study was undertaken in thirteen centers in
from the metal backing. The rare fracture of the porous coated four countries. Pre-operative data was collected and patients were
followed for two years post-operatively. Pre-operative details of
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

metal femoral components was most commonly related to

metallurgical problems while failures of the tibial trays were the patient’s demographics; socioeconomic status (education and
commonly a result of design and fixation. Many failures of income); height; weight and co-morbid conditions were
cementless components were a result of oxidation and subse- obtained. The WOMAC and SF-36 scores were also obtained.
quent fatigue of the polyethylene as well as limitations of first Patients with a lower income had a significantly worse pre-oper-
generation designs. Properly produced polyethylene should ative WOMAC pain (p equals 0.021) and function score (p equals
dramatically reduce the frequency of fatigue and more educated 0.039) than those with higher incomes. However, income did not
design and metallurgy should all but eliminate failed femoral have a significant impact on outcome at final follow-up. Level of
and tibial components. Bonding of the bearing to the ingrowth education did not correlate with pre-operative scores or with
surface of tibial and patellar components can reduce backside outcome at any time during follow-up. Across all four countries,
wear and the potential for separation. patients with lower incomes appeared to have a greater need for
Total Knee Arthroplasty. However, level of income and educa-
POSTER NO. P158 tional status did not appear to affect the final outcome following
Total Knee Arthroplasty. Patients with lower incomes appeared
Comparison of High Flexion TKA Patellofemoral
able to compensate for their worse pre-operative score and obtain
Kinematics similar outcomes post-operatively. These findings are in contrast
Filip Leszko, MSc, Knoxville, TN (a – Zimmer) to studies on other medical conditions and surgical interventions,
Adrija Sharma, Knoxville, TN (a – Zimmer) in which a lower socio-economic status has been found to have
Richard D Komistek, PhD, Knoxville, TN (a – Zimmer) a negative impact on patient outcomes.
Harold E Cates Jr, MD, Knoxville, TN (n)
POSTER NO. P160
Giles R Scuderi, MD, New York, NY (n)
Abstract: It is hypothesized that patellofemoral kinematics, in Revision Total Knee Arthroplasty with a Hybrid
deep flexion, may lead to higher bearing surface forces. This Technique Using Uncemented Fluted Stems
study compares the patellofemoral joint kinematics for two high Arthur L Malkani, MD, Louisville, KY (e – Stryker)
flexion designs- the Nexgen PCR TKA and the LPS Flex PS TKA Michael A Masini, MD, Ypsilanti, MI (e – Stryker)
with that of normal knees. Thirty subjects, ten in each group,
Madhusudhan Reddy Yakkanti, MD, Louisville, KY (n)
were studied using video fluoroscopy in the sagittal plane while
Dale Baker, BA, Louisville, KY (n)
flexing their knee from full extension to a squatting position.
Digitized frames at 0º, 30º, 60º, 90º and 120º of flexion were Abstract: The purpose of this study is to report our results of revi-
analyzed for the patellofemoral contact point, patellar tilt and sion knee arthroplasty with uncemented intramedullary stems
using an offset which provides independent and optimum place-

462 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 463

ment of the tibial and femoral component. 119 patients under- POSTER NO. P162
going revision knee arthroplasty with an average age of 67 years Multi-Surgeon Analysis of MIS and Mini-Standard
(range, 47-87 years) were retrospectively reviewed. Average follow
up was 40 months (36-70 months). In all patients a hybrid tech- TKA Techniques: Clinical and Economic Outcomes
nique was utilized where the tibial tray of the femoral compo- Jay A Katz, MD, Tucson, AZ (a, e – Zimmer)
nent was cemented into the metaphysis with a press-fit fluted Michael A Parseghian, MD, Tucson, AZ (a – Zimmer)
intramedullary stem. Patients were evaluated clinically using the James H Levi, MD, Tucson, AZ (a, e – Zimmer)
Knee Society Pain and Function Scores. Average preoperative Nebojsa V Skrepnik, MD, Tucson, AZ (a – Zimmer)
Knee Society Pain Score was 39 points which improved to 68 Suzanne M Rhodes, Med Student (a – Zimmer)
points (p<0.05). Average Knee Society Function Score was 58
Nicole A Feuring, BA (a – Zimmer)
points which improved to 79 points (p<0.05). A majority of
patients utilized an 80 mm stem with varying diameters. Average Abstract: A multi-surgeon, prospective study assessed the short
stem diameter was 16.8 mm. There were a total of 58 tibial offsets and long-term clinical and economic benefits of MIS versus
utilized and 28 femoral offsets utilized. The tibial offsets varied Mini-Standard approaches for primary TKA. Two surgeons
from 4 mm-8mm. There were 3 failures requiring revision, 1 for performed a total of 319 TKA cases, from September 2003 to
infection, 1 instability, and 1 for periprosthetic fracture. Results of January 2005, with 179 patients in the MIS group and 140
this study using a hybrid technique for revision total knee arthro- patients in the Mini-Standard group. Data collected included
plasty demonstrated excellent clinical results. Using an offset demographic information with BMI, length of hospital stay,
provided independent press-fit stem fixation allowing rigid hospital cost, discharge disposition, rehabilitation outcomes
cortical contact with the fluted stem. Long-term results made it and Knee Society Scores. Data was collected preoperatively, and
necessary to see if the hybrid technique achieves results similar to at 10 days, six weeks, three months, six months and one year
cemented stem fixation postoperatively. Average hospital LOS was 2.3 days for MIS
group and 2.9 days for Mini-Standard group. Preoperative range
POSTER NO. P161 of motion was 109 degrees and 106 for the MIS and Mini-
Standard groups respectively, and improved to 115 and 110
Leg Swing and Arthritic Knee: Did We Miss the degrees at six weeks. At one year post-op, average range of
Important Part? motion was 123 degrees and 119 degrees for MIS and Mini-
D Kevin Lester, MD, Fresno, CA (d – Minisun) Standard respectively. Preoperative KSS Functional Scores were
Kuan Zhang, Prof, Shanghai, China (n) 48 (MIS) and 51 (Mini-STD) and improved to 91 (MIS) and 86
Abstract: In free-living gait analysis the swing phase is important (Mini-STD) at one year. Preoperative KSS Knee Scores were 40
but less studied in arthritic patients. Swing phase measurement (MIS) and 44 (Mini-STD). At one year post-operatively, the KSS
may offer the most important data to determine functional Knee score improved to 90 (MIS) and 71 (Mini-STD).
benefit of knee arthritis interventions. Walking was evaluated Economically, there were noticeable cost savings differences
during 2 separate 200 meter tests before and after local anes- between the two procedures. There are short and long-term clin-
thesia injection in the arthritic knee of 26 patients. Standard gait ical benefits to using both MIS and Mini-Standard techniques.
Increased range of motion and better patient reported outcomes

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

parameters were used including stance (single limb support and
double limb support), swing (pulling power and swing power) were shown with both procedures. In a multi-surgeon group
ground impact, step length, cadence, and velocity. After injection practice, these findings may affect the perceptions of using newer
of Xylocaine, most improvement was noted in the swing phase surgical techniques.
of gait: initial swing, terminal swing, and ground impact
POSTER NO. P163
changed 10.3%, 6.8%, and 4.2% respectively (p=0.001, 0.003,
0.003). Velocity and cadence improved 3.3% and 2.8% (p=0.016 Does Patient Weight Determine Longevity of the
& 0.005). SLS improved 1.3% but was not statistically signifi- Primary Implant in Total Knee Arthroplasty
cant. The swing phase of gait was most effected by pain relief in
the arthritic knee. Thus, swing leg momentum may have mani-
Revision
fested in improved velocity, cadence, ground impact, SLS and Khaled J Saleh, MD, Charlottesville, VA
fatigability. SLS and velocity are commonly used to measure (a, e – Stryker, a, c, e – Smith Nephew)
improved walking function. SLS and velocity did not change as Kevin James Mulhall, MD, Dublin, Ireland (n)
much as swing phase measurements. This is the first method to Quanjun Cui, MD, Charlottesville, VA (n)
examine the swing phase of patients during free walking and its William Michael Mihalko, MD, Charlottesville, VA
contribution to standard gait laboratory measurements. The (a, e – Stryker)
swing phase of gait changed significantly and may be the impor-
Abstract: Although conventional thinking has implicated weight
tant and yet little recognized area of measurement for arthritic
and body mass index (BMI) in premature failure of total knee
knee patients.
arthroplasty (TKA) there is scant evidence of this belief. We
performed this study to assess the effect of weight on the
longevity and outcomes following TKA revision (TKAR). 186
consecutive subjects undergoing TKAR in a 17-center prospective
cohort study, had data collected on weight (pounds), BMI and
time elapsed between primary and revision surgery. The Physical
Component Score (PCS) of the Short Form-36 (SF-36), the
Western Ontario and McMaster Universities Osteoarthritis
(WOMAC) Index, and the Knee Society Score (KSS) were
collected preoperatively and at 6-month follow-up. Univariate,
bivariate and multivariate statistical methods were used in the
analysis. The mean BMI and weight were 31.8 (54 percent of

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
463
PPSE 07:Layout 1 1/12/07 1:41 PM Page 464

subjects had a BMI less than 30) and 200 pounds (range 107- to determine the radiographic limb alignment. A paired t-test was
350). The distribution of both measures of excessive weight was used to compare radiographic limb alignment to the alignment
close to normal. Average time between primary and revision determined by EM navigation. A post hoc power analysis was
procedures (T) was 7.3 years (range 6 months to 27 years). Using done to confirm that the sample size was large enough to deter-
linear regression, T significantly decreased as weight (BMI) mine significance. The mean difference in pre-operative limb
increased. Mean SF-36 PCS, WOMAC and KSS-Function scores alignment was 1.33 degrees (95% C.I. +/- 0.54 degrees), with a
were significantly improved 6 months after revision surgery. median of 0.9 degrees, and a range 0.2 ‘ 4.0 degrees. For post-
However, BMI and, weight were predictive of worse physical operative limb alignment, the mean difference was 1.71 degrees
functional outcomes. This study demonstrates the deleterious (95% C.I. +/- 0.6 degrees), with a median of 1.7 degrees, and a
effect of weight on the longevity of primary TKA as assessed at range of 0.1 to 4.2 degrees. EM navigation confirmed the align-
the time of revision and on functional outcomes following ment within 4.2 degrees of the radiographic measurement for
TKAR. Although further prospective data regarding this popula- every patient, and within three degrees in 90% of the cases. Inter-
tion is indicated, the current findings direct us towards better and intra-class correlation coefficients were used to assess the reli-
outcomes prediction for overweight patients. ability of x-ray measurements (ICC 0.88 and 0.80). The results
indicate that EM navigation can be used in a clinical setting to
POSTER NO. P164 accurately assess limb alignment during TKA.
In Vivo Analysis of Tibial Rotation in TKA:
POSTER NO. P166
Tibiofemoral Coupling vs Tibial Tubercle Referencing
Analysis of Failed Non-modular Constrained
Thomas E Varney, MD, Santa Rita, GU (n)
James Nairus, MD, Bolton, MA (n) Condylar Polyethylenes in Primary TKR
Abstract: Malrotation of total knee replacement components has Douglas E Padgett, MD, New York, NY (n)
been shown to have potentially severe consequences on Christopher Michael Farrell, MD, Fair Haven, NJ (n)
outcomes in total knee replacement. Many references exist in the Jonathan Gelber, MS, New York, NY (n)
literature regarding femoral rotation, but studies addressing Joselyn Cottrell, MS (n)
proper rotation of the tibial component are relatively underrep- Timothy M Wright, PhD, New York, NY (n)
resented. One of the classic landmarks used to determine proper Abstract: There is increasing experience with non-modular (non-
rotation of the tibial component is the medial one-third of the stemmed femoral components) constrained systems to augment
tibial tubercle. We aimed to elucidate the angular difference in stability in primary TKR. Little clinical data is available regarding
tibial rotation between the tubercle referencing method and the performance. Our goal was to evaluate the damage of the poly-
tibiofemoral coupling method in a given population. This study ethylene posts in a series of retrieved non-modular constrained
includes 184 primary total knee replacements performed by one condylar implants. 56 implants in 56 knees (35 female, 21 male)
surgeon (JN) at one center. Intraoperative marks were made at with a mean age of 66 were identified from our implant archive.
the medial one-third of the tibial tubercle and at the center point Index diagnosis was OA in 46, TA in 6, and RA in 4 (41 valgus,
of the tray when final rotation was coupled with the femur. The 15 varus) with instability the reason for constraint. Implants
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

difference between these marks was then recorded and were revised at a mean of 21.2 months (range 1 ‘ 76 mos): infec-
converted to an angular measure based on the tray size. tion in 20 (36%), loosening in 15 (27%), unexplained pain in
Although the average rotational difference ranged from -1 to 1 10 (18%), stiffness in 6 (11%), instability in 4 (7%), and poly-
degree depending on component design, there was significant ethylene failure in 1 knee (2%). Post analysis was performed
variability and outliers. Thirty-seven percent of knees showed from 5 directions (front, back, each side and superior view) and
greater than 5 degrees rotational difference from the tibial each then divided into quadrants. Damage scores were obtained
tubercle, and seven percent of knees showed greater than 10 by grading each quadrant for damage mode and extent (0 to 3)
degrees of rotational difference. With this population variability by a blinded reviewer All implants demonstrated evidence of
in mind, and in light of the push towards more conforming polyethylene damage with pitting and burnishing the most
articulations to decrease edge loading, surgeons should be common. Greatest damage scores were observed in implants
discouraged from using a fixed anatomic landmark to determine revised for loosening, instability, or polyethylene failure. Lowest
tibial component rotation in total knee arthroplasty. damage scores were for implants revised for stiffness or infec-
tion. Loads applied to constrained implants result in polyeth-
POSTER NO. P165 ylene damage regardless of mode of failure. The extreme
Accuracy of Electromagnetic Navigation for Total polyethylene damage observed suggests that reliance upon poly-
Knee Arthroplasty ethylene post for stability is insufficient.
Rodney K Alan, MD, Sumter, SC (n) POSTER NO. P167
Alfred J Tria Jr, MD, Princeton, NJ (e – Zimmer)
Antonia Chen, BS (n)
Increased Post-Operative Pain Following Minimally
Abstract: Although the basic science of electromagnetic (EM) Invasive Total Knees
navigation for TKA has been established, its accuracy in a clinical Stefano Alec Bini, MD, San Francisco, CA (n)
setting has not been confirmed. Several potential sources of error Liz Paxton, MA, San Diego, CA (n)
can affect its use during surgery. The purpose of this study was to Maria Carolina Secorun Inacio, MS, Irvine, CA (n)
compare limb alignment and component position determined Abstract: Our aim was to determine if minimally invasive tech-
by EM navigation to limb alignment and component position niques improved post-operative outcomes when controlling for
determined by mechanical axis radiographs. Twenty consecutive perioperative therapy protocols and pain management. Single
patients undergoing TKA with EM navigation were analyzed pre- surgeon series of 139 consecutive Total Knees, 50 performed
and post-operatively with mechanical axis x-rays. The mechanical using MIS techniques and 89 through standard incisions. All
axis radiographs were measured by three independent observers data points collected were compared to all total knees in our

464 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 465

registry to control for patient selection. All patients underwent POSTER NO. P169
the same pre and post operative management. 89 standard and Clinical Experience with Selective Patellar
50 minimally invasive total knees were identified and compared
to 19,956 TKAs in the registry. No significance differences were Resurfacing with NexGen Legacy Posterior
identified in age, pre-operative ambulatory support, and height Stabilized (LPS)
between all 3 groups. The MIS group had a higher number of D Gordon Allan, MD, Springfield, IL (a – Zimmer)
women and lower weight than both standard and registry Brad Dyrstad, BS (n)
patients. The study cohort’s patients tended to have a lower
William Thomas Payne, V MD, Springfield, IL (n)
range of motion and more pain than the registry. Operative time
and blood loss were not significantly different between standard Joseph C Milbrandt, PhD (n)
and MIS group but were both significantly lower than registry Abstract: Resurfacing the patella during total knee arthroplasty
TKAs. At 6 weeks, the only significantly different variables were (TKA) has been widely debated. Recommendations include not
increased pain (p=0.02) in the MIS group. There were no signif- resurfacing in younger patients (less than 60) or those with mild
icant differences at 3 months, one year, or two years between any patellar arthritis and a well-tracking patella, and if a patella-
group When controlling for peri-operative pain management friendly prosthesis is used. This study examined the clinical
and therapy, MIS surgery was associated with more pain and less outcome of patients who received the NexGen LPS device and
flexion at 6 weeks than standard incision procedures. There underwent patellar resurfacing versus those that did not. This is
seems to be no benefit to minimally invasive (<10cm) tech- a prospective, non-randomized trial involving a single operative
niques at longer follow up. We do not recommend the proce- surgeon. Subjects inclusion required a minimum of 5 years
dure over standard total knee surgery. follow-up after receiving the NexGen LPS device. Standardized
questionnaires, physical examinations, and radiographic evalua-
POSTER NO. P168 tions were obtained and collected annually. Subjects were sorted
into two groups, those with patellar resurfacing and those
Use of Lidocaine with Epinephrine Injection to without. 81 patients consisting of 89 knees (43 resurfaced, 46
Reduce Blood Loss in MIS Total Knee Arthroplasty not resurfaced) were included. No statistical differences were
Raymond Hyungchan Kim, MD, Highlands Ranch, CO seen between the two groups in Knee Society Score (KSS) func-
(n) tion, KSS assessment, Hospital to Special Surgery knee scale,
Giles R Scuderi, MD, New York, NY (n) pain, activity level, range of motion, and patient satisfaction.
Fred D Cushner, MD, New York, NY (n) Mean patient age for resurfacing group was 70.5 versus 62.3
years (less than 0.001). The average weight for the resurfaced
Michael A Kelly, MD, New York, NY (n)
group was lower than the no resurfacing group, but this was not
W Norman Scott, MD, New York, NY (n) statistically significant (184 lbs versus 204). Patients selected for
Shani Lee Junger, DO, Atlantic Beach, NY (n) no patellar resurfacing had comparable clinical outcomes to
Abstract: This study was performed to evaluate blood loss in those patients who underwent resurfacing. No resurfacing can be
patients undergoing minimally invasive total knee arthroplasty considered in young patients if using a patella-friendlyprosthesis
with use of a lidocaine with epinephrine injection. Three groups

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

such as NexGen LPS. This choice can be made regardless of
were identified: Group A consisted of 53 consecutive patients patellofemoral disease and may effectively save operating room
who underwent MIS TKA in association with injection of 30cc of time and equipment costs.
1% lidocaine HCl with epinephrine (1:100,000) along the antic-
ipated arthrotomy site and into the fat pad, Group B consisted POSTER NO. P170
of 59 consecutive patients who underwent MIS TKA alone, and Bupivacaine Levels in the Reinfusion Drain after
Group C consisted of a retrospective cohort of 124 patients who
underwent TKA using a standard exposure. Preoperative hemo- Periarticular Injection During TKA
globin levels were obtained within 2 weeks of surgery. No Carl A Deirmengian, MD, Philadelphia, PA (n)
patients donated autologous blood. Postoperative hemoglobin Linda Abella, ONC, Aurora, IL (n)
levels were drawn on postoperative day number three for Wayne Gregory Paprosky, MD, Winfield, IL (a – Zimmer)
comparison in all patients. The average preoperative hemo- Scott M Sporer, MD, Wheaton, IL (a – Zimmer)
globin in Group A was 13.2 g/dL, 13.8 g/dL for Group B, and
Abstract: The implementation of rapid-recovery protocols is
13.9 g/dL in Group C. The average postoperative hemoglobin in
improving the perioperative care of arthroplasty patients. Both
Group A was 11.12 g/dL, 11.0 g/dL in Group B, and 10.5 g/dL in
periarticular local anesthetic injections and blood reinfusion
Group C. The preoperative to postoperative decrease in hemo-
drains are being utilized. The purpose of this study is to measure
globin in Group A averaged 2.05 g/dL, 2.78 g/dL for Group B,
the local anesthetic levels in the blood to be reinfused from the
and 3.37 g/dL for Group C. Although the difference in blood
drain after surgery. 10 TKA patients were included. 30cc of 0.25%
loss between Groups B and C was not significant (p=0.134), the
bupivacaine with epinephrine (1:200,000) were injected into
differences between Groups A and B (p=0.01) and Groups A and
the synovium, capsule, and periarticular tissues before arthro-
C (p<0.01) were statistically significant. The use of lidocaine
tomy closure. Reinfusion drains were used, with blood reinfu-
with epinephrine injection in conjunction with a minimally
sions at 4 and 8 hours. Bupivacaine levels in the drained blood
invasive approach is beneficial for reducing blood loss in total
were measured. The bupivacaine levels in the reinfusion blood
knee arthroplasty.
were far below the toxic serum threshold. At the 4 hour infusion,
the average bupivacaine returned to the patient’s blood volume
was 632 mcg (range 100-1716mcg). At the 8 hour interval, the
mass returned to the blood volume was 265 mcg (range 49-960
mcg). The resulting serum concentration of bupivacaine from
reinfusion blood would only reach 0.15 mcg/ml, which is 27
times lower than the toxic threshold. The total bupivacaine in

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
465
PPSE 07:Layout 1 1/12/07 1:41 PM Page 466

the reinfusion blood was only 1% of the total bupivacaine used POSTER NO. P172
as local anesthetic. Only a small percentage of local anesthetic Improved Wear Performance of Sequentially
injected into the periarticular tissues during TKA is found in the
reinfusion drain 4-8 hours after surgery. The reinfusion of this Enhanced Polyethylene in Knee Simulation Study
blood does not threaten to cause bupivacaine toxicity. If much Riichiro Tsukamoto, Loma Linda, CA (n)
higher concentrations of local anesthetic are being injected, we Mikiko Tsukamoto, MD (n)
recommend testing drug levels before reinfusing the blood. Hiromu Shoji, MD, Riverside, CA (n)
Giuseppe Pezzotti, PhD (n)
POSTER NO. P171
Ian C Clarke PhD, Loma Linda, CA (a – Stryker)
Isometric and Isokinetic Strength Testing of Abstract: Highly crosslinked polyethylenes have demonstrated
Minimally Invasive Total Knee Arthroplasty Recovery less volumetric wear than non-crosslinked polyethylenes in
William C Schroer, MD, Saint Louis, MO (a, e – Biomet) laboratory knee studies. However, XLPE has not found wide-
Paul Diesfeld, PA-C, Saint Louis, MO (a – Biomet) spread in clinical use because crosslinking processes inevitably
lead to reduction in critical mechanical properties such as tough-
Mary E Reedy, RN, Saint Louis, MO (a – Biomet)
ness and fatigue strength. Thus improvements sought for have
Angela LeMarr, RN, Saint Louis, MO (a – Biomet) included improved mechanical and oxidation properties.
Abstract: Quadriceps weakness for up to two years may follow Compression molded GUR1020 UHMWPE was processed by
traditional total knee arthroplasty (TKA) utilizing a medial para- irradiating to 30 kGy followed by annealing at 130°C for 8
patellar arthrotomy. Minimally invasive (MIS) TKA techniques hours. This cycle was repeated twice sequentially resulting in a
avoid both the quadriceps arthrotomy and patella eversion in an cumulative dose of 90 kGy (SXPE). CR tibial inserts were
effort to improve functional recovery; however, few studies have machined from SXPE and 3-Mrad DurationTM stock (Stryker
investigated this objectively. We utilized isokinetic muscle testing Inc: controls). SXPE inserts were gas-plasma sterilized. Knee
to evaluate recovery following unilateral MIS TKA using the mini- simulation was conducted on a 6 station simulator. Lubricant
subvastus technique. Fifty-one patients (14 male, 37 female) was serums (20mg/ml protein) with additive EDTA. Serum was
underwent unilateral posterior-stabilized TKA by the same changed every 0.5 Mc until 5 Mc durations and then every 1 Mc
surgeon using the mini-subvastus technique. Patient demo- until 10 Mc duration and wear trends assessed by linear regres-
graphics were similar to our entire primary MIS TKA population. sion techniques. Microscopic characterization was carried out on
Post-operative management focused on knee range of motion. the polyethylene tibial inserts using confocal Raman microprobe
Outpatient physical therapy was not employed. Isokinetic testing spectroscopy (irradiation with a blue laser with wavelength 488
at 60º per second was performed on both knees pre-operatively, nm) after 10 Mc durations. The wear showed uniform linear
and then at 6, 12, 24, and 48 weeks post-operatively. Quadriceps trending for the control implants (CoCr / UHMWPE) averaging
and hamstring strength, percent recovery from pre-op strength, 3.2 mm3/Mc. Wear of the SXPE implants averaged 0.46
and hamstring to quadriceps (H/Q) strength ratio were deter- mm3/Mc. The most significant finding was that the SXPE tibial
mined. Comparison to the non-involved knee was made at each inserts reduced wear by 7-fold compared to control. Thus SXPE
follow-up evaluation. Relative quadriceps strength of the surgical implants may prove excellent for active patients who may other-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

knee at pre-op, 6, 12, 24, and 48 weeks was 1.00, 0.94, 1.11, 1.20, wise risk high wear rates over many years of use.
and 1.26 respectively. Quadriceps strength at 12 and 24 weeks
was greater than pre-op, p=0.04 and 0.002 respectively. At one POSTER NO. P173
year post-op, the surgical knee quadriceps strength was equiva-
lent to that of the non-involved knee. Mean H/Q ratios were
Outcomes of Intra-Operative Procedure Selection:
normal (0.5-0.8) throughout follow-up: 0.75 at 6 weeks, 0.77 at Unicompartmental Versus Total Knee Arthroplasty
12 weeks, 0.73 at 24 weeks, and 0.75 at one year. Strength testing Marshall Kuremsky, MD, Charlotte, NC
demonstrated a rapid recovery of quadriceps strength following (a – Synthes, Zimmer)
mini-subvastus TKA. Published studies of traditional TKA have Owen B Tabor Jr, MD, Memphis, TN (*)
shown persistent quadriceps weakness at up to two years and John Leander Masonis, MD, Charlotte, NC (*)
H/Q ratios that were elevated due to relative quadriceps weak-
ness. In this study, the mean quadriceps strength was greater than
POSTER NO. P174
the pre-operative value 12 and 24 weeks after MIS TKA and was
equal to the non-involved knee at one year. The H/Q ratio The Impact of Morbid Obesity on Clinical Outcome
remained normal throughout recovery signifying less quadriceps in Patients Following Total Knee Arthroplasty
damage and an overall more rapid recovery. The results of this Vai Rajgopal, MD, London, Canada (n)
study provide further evidence to support use of the mini-
Bert M Chesworth, PhD (n)
subvastus TKA technique.
Robert Barry Bourne, MD, London, Canada
(a, e – Smith & Nephew, a – Depuy, Zimmer)
Steven J MacDonald, MD, London, Canada
(a, e – Depuy, a – Smith & Nephew)
Richard W McCalden, MD, London, Canada
(a, e – Smith & Nephew, a – Depuy, e – Stryker)
Cecil H Rorabeck, MD, London, Canada
(a – Smith & Nephew)
Abstract: In 2002-2003 there were 26,500 total knee replace-
ments performed in Canada. In 2004, 23.1% of adult Canadians
were classified as obese. The World Health Organization (WHO)
classifies overweight adults according to the following BMI values

466 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 467

(kg/m2). Normal = 18.5-24.9, Overweight = 25-29.9, Class I tent across all patients with little variation. Reinfusion drains
Obese = 30-34.9, Class II Obese = 35-39.9, and Class III Obese e and LA infiltration have both been shown to be useful tech-
40 (morbidly obese). The relationship between morbid obesity niques in TKA. Combined usage of these techniques carries a
and clinical outcome following TKA is inconclusive. The purpose theoretical risk of LA toxicity. This study carefully assessed this
of this study was to investigate the impact of morbid obesity on issue, and at no time did venous plasma concentrations reach
clinical outcome in patients following TKA. 550 patients who levels to cause concern. A significant amount of ropivicaine was
underwent a primary TKA, and had pre-operative and 1-year present in the blood drainage bag, ropivicaine was detectable in
WOMAC scores were included. Exclusion criteria included a diag- serum post femoral nerve block, and after injection into the knee
nosis other than osteoarthritis, another TKA during follow-up of capsule, and there was no significant increase in circulating
index knee arthroplasty, and BMI < 18.5. Patients were then strat- venous concentrations as a result of reinfusion. This study has
ified into a morbidly obese group and other patients group. The demonstrated that use of reinfusion drains in the presence of a
first analysis (independent t-test) was used to determine if a combined femoral block and local infiltration to the surgical site
difference existed in the pre-operative and 1-year WOMAC score is a safe practice, allowing the benefit of effective postoperative
between morbidly obese patients and all other patients. The pain relief and the safe use of autologous reinfusion.
second (multi-variable linear regression) was used to determine
the relationship between morbid obesity and both the 1-year and POSTER NO. P176
pre-operative WOMAC score. The independent t-test revealed Randomized, Double-Blind Study of Pulsed
that morbidly obese patients had significantly lower pre-opera-
tive WOMAC scores (p < 0.001). Morbidly obese patients also
Electrical Stimulation In Osteoarthritis Of The Knee
had significantly lower one-year WOMAC scores (p < 0.001). Michael A Mont, MD, Baltimore, MD (d – Bionicare)
Regression analysis demonstrated that morbid obesity negatively Douglas Edward Garland, MD, Long Beach, CA
influenced pre-operative (p<0.05) and post-operative WOMAC (e – Bionicare)
score (p<0.05). Morbid obesity negatively impacts clinical Andrew Hooper, MD, Brighton, VIC Australia (e – Bionicare)
outcome in patients following total knee arthroplasty. Jacques Caldwell, MD (e – Bionicare)
Thomas M Zizic, MD (e – Bionicare)
POSTER NO. P175
German A Marulanda, MD, Baltimore, MD (n)
The Safety of Combined Usage of Local Anaesthetic Abstract: The non-operative treatment of osteoarthritis of the knee
Infiltration and Reinfusion Drains in TKA has been a matter of constant controversy. The recent withdrawal
David Parker, MD, Sydney, Australia (n) of COX-II selective non-steroidal anti-inflammatory agents, and
Myles Raphael Coolican, MD, Chatswood, Australia (n) the unfavorable results of the NIH sponsored trial of
Glucosamine/Chondroitin sulfate have reduced the available
David Graham, MD (n)
options for the non-surgical management of osteoarthritis of the
Robert A Preston (n)
knee. The purpose of this trial was to determine if a specific pulsed
Abstract: Injection of high dose local anaesthetic (LA) into the electrical signal produced by a capacitive coupling device could
soft tissues at the time of Total Knee Arthroplasty (TKA) has been improve signs and symptoms of knee osteoarthritis in patients

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

shown to aid postoperative pain relief and reduce the need for with moderate to severe disease who responded inadequately to
opiate analgesia. Reinfusion drains have also proven useful in medication and other non-operative treatments. Fifty-eight
decreasing the need for allogenic blood transfusion. Combined patients with moderate to severe osteoarthritis of the knee entered
use carries the risk of reinfusion of LA that may be present in the a double-blind, placebo-controlled trial. Patients in the study
drainage bag, causing serious side effects. There is currently no group used the device (BioniCare Medical Technologies, Inc.
literature examining this subject, and the aim of this study is Sparks, Maryland) at home for a minimum of 6 hours per day for
therefore to determine the safety of combining the usage of LA 3 months. Outcome measures included patient global evaluation
infiltration with reinfusion drainage systems. At a two surgeon of response, patient measurement of knee pain using a 100
practice, 27 consecutive patients undergoing unilateral TKA for millimeters Visual Analog Scale (VAS scale), and the Western
primary osteoarthritis were enrolled after ethics approval was Ontario and McMaster Universities (WOMAC ) questionnaire. All
obtained. Exclusion criteria included rheumatoid arthritis, use of inter-group differences favored the actively treated patients.
spinal/ epidural anaesthetic, and if no tourniquet was used. All Percent changes from baseline in patient global evaluation of
patients received a 150mg Ropivicaine femoral nerve block, response was 50.6 (p = 0.03), in patient pain 31.2 (p= 0.04), in
followed by general anaesthetic. A tourniquet was used in all WOMAC stiffness 25.1 (p = 0.03), in WOMAC function 29.5 (p =
cases. Local infiltration using a solution of 150 mg Ropivicaine, 0.01) and in WOMAC pain 19.9 (p = 0.11). The percentage of
0.5 mls of 1:1000 adrenaline in 100mls saline was infiltrated patients who improved 50% from baseline favored the active
into the joint capsule just prior to implant insertion. A dedicated group in all outcome measures: patient global evaluation 38.5 vs.
intravenous cannula was placed in the arm not being used by the 5.3 (p = 0.01); knee pain 43.6 vs. 15.8 (p = 0.04); WOMAC pain
anaesthetist, and nine samples were taken. This included 38.5 vs. 10.5 (p = 0.03); WOMAC stiffness 28.2 vs. 5.3 (p = 0.08);
samples prior to femoral nerve block, post tourniquet release, and WOMAC function 23.1 vs. 5.3 (p = 0.14). Twenty-one per
and after reinfusion. A sample was also taken from the drainage cent of placebo and 18% of actively treated patients developed a
bag immediately prior to reinfusion. Ropivicaine assays were transient rash at the site of the electrodes. No unanticipated
performed on each sample by high performance liquid chro- adverse device effects on internal organs were reported and no
matography. 20 patients had blood reinfused and were therefore serious side effects occurred during the length of the study and at
included in the analysis. A mean volume of 412 ml of blood was final follow-up. The pulsed electrical stimulation device used in
reinfused, at a mean time of 268 minutess postoperatively. Mean this study significantly ameliorated symptoms and improved
ropivicaine concentration in the drainage bag prior to reinfusion function in osteoarthritis of the knee without producing any
was 3.2ug/ml, and the mean maximum venous concentration systemic side effects. A parallel study is being developed to corre-
post reinfusion was 0.84 ug/ml (Range 0.38-1.3). ( Toxic effects late these findings to deferral of knee arthroplasty and improve-
of ropivicaine commence at 6ug/ml). Results were very consis- ment in clinical and radiographic scores for osteoarthritis.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
467
PPSE 07:Layout 1 1/12/07 1:41 PM Page 468

POSTER NO. P177 wound cultures demonstrated low sensitivities of 0.15 and 0.09,
Expanded Indications for Patellofemoral Joint respectively. The predictive value for a negative test was also
similar for the two groups with the aspiration gram stains
Replacement: A Retrospective Review showing a value of 0.31 compared to 0.44 for the intra-operative
Thomas M Smith, DO, Lansing, MI (n) sample results. Neither group had any false-positive results, and
James Lebolt, DO, Birmingham, AL (n) thus showed 100% specificity and predictive value for a positive
David A Shneider, MD, East Lansing, MI (n) test. The study demonstrated the poor sensitivity of gram stains
Abstract: Patellofemoral joint pathology is difficult to treat and obtained from both fluid and surgical-site tissues. Based on
many conservative and surgical options exist for this reason. these unpredictable, low outcomes, the investigators recom-
Recent studies have shown success treating degenerative changes mend that gram stains should no longer be considered an
with patellofemoral joint replacement (PFJR). Good short term appropriate method for diagnosing infections in total knee
survivorship and functional scores have been shown. Care of the arthroplasties. The current findings have immediate implica-
hypoplastic trochlea, as well as patella instability, has not tions for the authors practice which has abandoned gram stains
resulted in the clinical success desired. The purpose of this study from our diagnostic infection protocol.
is to evaluate the functional outcome of PFJR in difficult to treat
patellofemoral disorders. A retrospective review from a single
POSTER NO. P179
surgeon that performed PFJR utilizing the Depuy Low Contact Range of Motion after TKA: High-flexion PS vs CR
Stress PFJR in 28 patients (31 knees). Indications for surgery Implant in Prospective, Comparative Study
included: primary patellofemoral arthrosis, patellar instability,
Akihiko Nagao, MD, Hachinohe City, Japan (n)
failed previous patellar surgery, and prior patellectomy, either
separately or in combination. Irrgang’s ADL scale was utilized to Lamont J Cardon, MD, Berkeley, CA (n)
evaluate the post-operative function with two year follow up Hideki Sato, MD (n)
Twenty-five (80%) PFJR had good to excellent results, four fair, Yasuharu Hiraga, MD, Tokyo, NI, Japan (n)
and two failures that were converted to a total knee arthroplasty Abstract: Range of motion after total knee arthroplasty (TKA) is
(TKA). Nine (10%) subsequent surgeries including three lysis of one of the important variables in determining clinical outcomes.
adhesions, three alignment procedures, two conversions to a However, there is a controversy which is higher knee flexion, PCL
TKA, and one patella exchange from a mobile bearing to a sacrifice (PS) or retaining (CR). Our aim was to compare the
domed patella. With good to excellent short term results in range of motion of high-flexion PS and CR in a same manner.
recent literature, the component design and concomitant align- This was a prospective, comparative, single-surgeon study of
ment procedures will be important factors in determining outcomes in patients who had primary TKA using the
success. Extended follow up will be needed to evaluate the long NexGen®LPS-Flex and CR. The PS implant was used for 96 knees
term function of these patients. We conclude PFJR provides an and a CR was for 43 knees. The mean follow-up was 54 months.
excellent treatment option for a variety of patellofemoral disor- PS had a mean preoperative flexion of 125.1 degrees versus
ders. It is particularly useful in treating complicated patello- 122.7 degrees in CR. There were no significant differences
femoral maladies. between groups. PS had a mean postoperative flexion of 128.6
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

degrees versus 113.4 degrees in CR. Postoperative flexion was

POSTER NO. P178 significantly greater for the PS implant (p< 0.001). This study
Are Gram Stains Necessary for the Diagnosis of showed that high-flexion PS enabled deep knee flexion after
TKA, indeed. Mean flexion of 128.6 degrees was higher than the
Infected TKA? average values previously published for TKA. Preoperative ROM
Johannes F Plate, BS, Heidelberg, Germany (n) was supposed to be the most important factor in determining
Thorsten M Seyler, MD, Baltimore, MD (n) postoperative flexion. Because high-flexion PS had specific
David R Marker, BS, Baltimore, MD (n) features of design dedicated to accommodate deep flexion, PS
Ronald Emilio Delanois, MD, Lutherville, MD (n) knee allowed for no loss of motion. This study is the first study,
Michael A Mont, MD, Baltimore, MD to our knowledge, to compare the results of a single prosthesis
(a, e – Stryker Orthopaedics) that could be a high-flexion PS or CR implants, and high-flexion
PS would be suitable for the cases that needed deep flexion.
Abstract: Gram stains are considered to be a cost-effective, stan-
dard technique for testing total knee arthroplasty patients for POSTER NO. P180
infections. The two most common specimens used for gram
staining are joint aspirations and wound cultures. Recently, the Probability Distribution of Maximum Flexion of the
effectiveness and usefulness of gram stains in diagnosing infec- Knee after CR TKA
tion has been called into question. This study assessed the utility Jeremy F Suggs, BS, Boston, MA (n)
of gram stains from aspiration fluids and surgical-sites by George R Hanson, BS, Boston, MA (n)
comparing the results with cultures grown from the same
Guoan Li, PhD, Boston, MA (a – Zimmer)
samples. Between July, 1996 and May, 2006, 172 total knee
arthroplasties presented with indications for possible, deep joint Young-Min Kwon, MD, Boston, MA (n)
infection. In 18 cases, gram stains were obtained using joint Harry E Rubash, MD, Boston, MA (a, c – Zimmer)
aspirations, and in 154 cases, gram stains were collected from Andrew A Freiberg, MD, Boston, MA (a – Zimmer)
the operative site. In each of these cases, samples were sent to Abstract: Follow-up studies of TKA patients have reported
microbiology for additional culture analysis. The results from all average maximum flexion angles from 100° to 115°. The distri-
cases were used for standard calculations assessing sensitivity, bution of maximum flexion has not been well investigated.
specificity, accuracy, predictive value for a positive test, and While the mean value of maximum flexion for a cohort of
predictive value for a negative test. These values were then used patients may be satisfactory, the portion of patients below the
to determine the viability of utilizing gram stains to diagnose mean may have limited flexion. The objective of this study was
total knee arthroplasty infections. Both the aspiration and to investigate the distribution of maximum flexion after CR TKA.

468 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 469

Twenty-nine knees (15 CR, 14 CR Flex, Zimmer) were imaged. POSTER NO. P182
Patients performed a single-leg lunge while images of the knee A Convex Tibial Plateau Improves the Range of
were captured using a dual fluoroscopic system. The images were
used along with computer models of the components to deter- Movement and Kinematics for Mobile Bearing
mine the in-vivo kinematics. The distribution of maximum Lateral UKA
flexion was tested for normality using the Shapiro-Wilk W test John Anthony Gallagher, MD, Bribie Island, Queensland
and further analyzed. The mean maximum flexion angle was Australia (b – Biomet)
109±13°. Seven percent of the knees reached maximum flexion
Bernard van Duren, B Eng (a – Biomet)
between 80° and 90°, 17% between 90° and 100°, 34%
between 100° and 110°, 21% between 110° and 120°, 14% Hemant G Pandit, FRCS, Oxford, United Kingdom
between 120° and 130°, and 7% between 130° and 140°. CR (a, b – Biomet)
and CR Flex knees had similar distributions of maximum Harinderjit Singh Gill, PHD, Oxford, United Kingdom
flexion. The mean and range of maximum flexion is very similar (a – Biomet)
to what has been reported in the literature. Twenty-one percent Christopher A F Dodd, FRCS, Oxford, United Kingdom
of the patients were able to flex past 120° and 24% were unable (a, b, c – Biomet)
to flex past 100° during the single-leg lunge. Improvements in David W Murray, MD, Oxford, United Kingdom
TKA should help patients with the most limited flexion achieve (a, b, c – Biomet)
greater flexion.
David J Beard, DPhil, Oxford, United Kingdom (a – Biomet)
POSTER NO. P181 Abstract: Mobile bearing lateral unicompartmental arthroplasty
(UKA), using the Oxford Knee, has met with limited success.
Causes of Patient Dissatisfaction after Total Knee Whilst a high rate of dislocation was rectified by modified
Arthroplasty surgical technique, limited flexion presumed to be due to restric-
Chong Bum Chang, MD, Seongnamsi, Republic of Korea tion of femoral rollback remained a problem. A new convex
(a – Seoul National University Bundang Hospital Research tibial plateau with a bi-concave bearing was designed to address
Fund) this problem. This paper reports the kinematics for the new
device compared to the previous flat bearing device. Patients
Yeon Gwi Kang, MD, Seongnam-Si, Republic of Korea (n)
undergoing unilateral UKA for OA of the lateral compartment
Heon Jung, MD (n) were recruited for the study. Fifty one patients who underwent
Sang Cheol Seong, MD, Seoul, Republic of Korea (n) UKA with the new convex plateau were compared to 60 patients
Tae Kyun Kim, MD, Seongnam-si, Republic of Korea who had standard lateral UKA with a flat plateau. Kinematic
(a – Seoul National University Bundang Hospital Research evaluation was performed using an established fluoroscopic
Fund) technique which involved recording patella tendon angle (PTA,
Abstract: Total knee arthroplasty (TKA) is known as a highly angle between patellar tendon and tibial axis) and antero-poste-
successful procedure. However previous studies demonstrated rior bearing translation through full range of flexion. Terminal
range of flexion was also recorded. Clinical outcome was evalu-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

that more than 10% of patients have reported dissatisfaction
after surgery. In this study, we aim to evaluate the causes of ated using the Oxford knee score and American Knee Society
patient dissatisfaction after primary TKA in osteoarthritic Score. Both groups had PTA data similar to the native knee.
patients. We assessed the level of satisfaction in 375 knees (234 Bearing movement in the convex device mimicked that of the
patients) with uncomplicated primary TKA using a self-adminis- flat through the full flexion range until 100° flexion, at which
tered postal survey at a minimum of 1 year post-surgery. In the point the movement in the biconcave bearing translated poste-
first survey, we posed a simple question regarding level of patient riorly 9mm further than the flat bearing (p<0.005). This enabled
satisfaction graded as disappointed, noncommittal, satisfied, a significantly better range of movement for knees with the
and enthusiastic. For the patients who reported dissatisfaction domed device (125°as opposed to118°). Clinical outcome for
(disappointed or noncommittal), we identified the causes of the domed device was also significantly better. The use of a
their dissatisfaction by patient interview on telephone and convex tibial plateau in the lateral compartment with the Oxford
review of medical records and radiographs. 319 knees of 195 UKA improves kinematics and range of movement.
patients (85.1%) responded to the survey. Among our survey
respondents, 21 knees (6.6%) of 15 patients reported dissatis- POSTER NO. P183
faction (noncommittal in all). The reasons for dissatisfaction 10-Year Minimum Follow-Up of Medial
were as follows: 1) severe radiating pain originating from spine Unicompartmental Knee Arthroplasty with the
conditions in 6 knees of 3 patients (28.6%); 2) persistent knee
pain in 5 knees of 4 patients (23.8%); 3) vague knee symptoms Allegretto Prosthesis
in 3 knees of 2 patients (14.3%); 4) inability to do high flexion Prof Sergio Romagnoli, MD (c – Zimmer)
activities in 2 knees of 2 patients (9.5%); 5) unexplained reasons Francesco Verde, MD, Pietra Ligure SV, Italy (n)
in 5 knees of 4 patients (23.8%). This study demonstrates that Robert W Eberle, Apex, NC (e – Zimmer)
even in uncomplicated TKA, about 7% of patients are dissatis- Abstract: Unicompartmental knee arthroplasty was developed as
fied with their procedure. More than 50% of dissatisfactions an alternative to the finality of tricompartmental, total knee
after TKA result from the reasons not related to the knee symp- arthroplasty. Recent short-term and intermediate-term results
toms.For patients dissatisfied with TKAs,causes origintating from show favorable results when compared to the first generation
other sources need to be searched. results reported in the 1970’s and early 1980’s. The purpose of
this study was to report the long-term, single surgeon use of the
Allegretto unicondylar knee prosthesis. We evaluated 115 medial
unicompartmental knee arthroplasties that were implanted by a
single surgeon using the Allegretto prosthesis. The average age of

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
469
PPSE 07:Layout 1 1/12/07 1:41 PM Page 470

the patients at the time of surgery was sixty-eight years. No POSTER NO. P185
patients were lost to follow-up. Nineteeen patients were unable Arthroscopically-Supported Unicondylar
to continue longterm office follow-up and were contacted by
telephone. Thirty-four patients (thirty-five knees, 30%) died Replacement of Knee Joint Results of
from unrelated causes. None of the patients that died underwent Arthrosurface System
revision of the index UKA. Thus there were sixty-one patients Oliver Meyer, PhD, Herne, Germany (n)
available for prospective clinical and radiographic evaluation Georgios Godolias, MD, Herne, Germany (n)
beyond tenyears. The average time to follow-up for those
Abstract: Query: The treatment of discrete but advanced cartilage
patients available prospectively was 11.1 years. Clinical evalua-
damage to the knee joint, such as in osteonecrosis in patients
tions revealed an average pre-operative HSS score of fifty-four
older than 45 years, has not been satisfactorily resolved to date.
points which improved at the most recent post-operative follow-
The objective of this prospective study was to investigate the
up to an average of ninety-three points. At the most recent
utility of a minimally-invasive unicondylar surface replacement
average time to follow-up, the post-operative range of motion
system and to record the first clinically-obtained results. Method:
was assessed at an average of 0.3 degrees of extension through
We are reporting on the results of the first 19 operations of
124.4 degrees of flexion. Radiographically, no component
discrete knee joint defects performed in our clinic since October
showed evidence of loosening as defined as change in position
2004 using the Arthrosurface System. The Arthrosurface System
of the components on serial radiographs. Twenty-one knees
consists of specially-preformed convex implantate dowels and
demonstrated radiolucencies less than 2 mm of thickness and
an adapted integrative fraise system for handling the femur-
none were progressive. Provided correct patient selection and
condylus. The knee joint function, the activity level and the
technical expertise, the Allegretto UKA system allows for the
patients quality of life were evaluated pre- and postoperative
expected relief of pain, restoration of function and component
using the Knee Society Score, the Tegner Activity Index and the
survival in those patients with medial compartmental knee
Lysholm Score. Results: In the operating room, the system was
arthrosis through ten-years.
impressive in its utility. No implantate-related complications
POSTER NO. P184 have occurred in the short follow-up time thus far. In the early
postoperative phase, the patients achieved rapid increase in their
Revision Total Knee Arthroplasty with Modular activity level which paralleled the reduction in pain relief
Cemented Stems: Long-Term Followup attained. Conclusion: The Arthrosurface® System shows benefi-
Tad Meredith Mabry, MD, Rochester, MN cial properties for treating localized but advanced cartilage
(a – DePuy, Stryker Howmedica, Zimmer) damage to the knee joint of patients older than 45 years of age.
In particular, it enables arthroscopically-supported minimally-
Michael B Vessely, MD, Lake Oswego, OR (a – DePuy)
invasive implantation. Intact structures are thus not damaged
William Harmsen, MS, Rochester, MN (n) and the patient rehabilitation is rapid.
Daniel J Berry, MD, Rochester, MN
(a – Depuy, Stryker Howmedica, Zimmer c – DePuy) POSTER NO. P186
Abstract: To evaluate the results of revision total knee arthro- The Design of Current TKA Mismatch Anatomical
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

plasty (TKA) using modular, fully cemented femoral and tibial

stems. From 1989 to 1994, 73 knees in 72 consecutive patients Based MR Measurements of the Femoral Condyle
(mean age 73 years) requiring surgery for an aseptic, failed Andreas J Krueger, MD, Zurich, Switzerland (n)
primary TKA were treated at one institution with posterior stabi- Mario Moser, MD, Bern, Switzerland (n)
lized revision TKA of one design using modular, fully cemented Maximillian J Hartel, MD, Bern, Switzerland (n)
femoral and tibial stems. The indications for revision were Sandro Kohl, MD, Bern, Switzerland (n)
aseptic loosening (45), polyethylene wear (13), tibiofemoral Stefan Eggli, MD (a – Mathys Ltd, Bettlach)
instability (7), metal-backed patella failure (6), or other (2).
Abstract: Knee replacement designs are still remodeled because
Patients were followed until death, revision, or removal of
of new concepts based on biomechanical findings. General aim
components. Three patients (3 knees) died or were lost to
is the anatomic reconstruction of the shape of the articulare
follow-up within 2 years. The median follow-up of living, unre-
surface. Aberration in geometry in prosthesis design can cause
vised patients was 10.2 years. Four knees had both femoral and
instability, minor function and following pain in total knee
tibial components re-revised for aseptic loosening. One knee
replacement. Measurements on 100 MRI pictures were
was re-revised for patellar loosening and tibial polyethylene
performed with assessment of the femoral offset, the flexion and
wear. The mean time to re-revision was 8.5 years. Three other
extension centers of rotation as well as the anterior-posterior and
patients had reoperations: two for deep infection and one for
cranio-caudal dimension of the femoral condyles with PACS
late periprosthetic fracture. Five and ten year implant survivor-
(Picture Archiving and Computing System)integrated measure-
ship free of revision for aseptic failure was 98% and 92%, respec-
ment tools. The results were compared with market available
tively. The effects of patients’ age, gender, BMI, underlying
knee prosthesis. The obtained data support that current pros-
diagnosis, and use of bone grafts, metal augments, or antibiotic
thetic designs neither respect the real anatomy of the kneejoint
cement were analyzed and, with the numbers available, none
nor the center of rotation of the femoral condyle. The anatom-
had a statistically significant effect on survivorship. These data
ical circumstances of the femoral condyle are not exactly taken
provide the first long-term follow-up information on revision
into consideration with current replacement models. As a result,
TKA with modular components using fully cemented stems.
limited mobility, non-physiological kinematics and persistent
Survivorship was comparable to early series of non-modular
pain can be observed. The gathered data can be used as a basis
cemented stems and favorable to recent shorter term follow-up
for future TKR designs with improved kinematics.
series of modular uncemented stems.

470 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 471

POSTER NO. P187 PS, and 5 to a constrained design. The predominant mode of
Hypoxia after Total Joint Arthoplasty: A Problem on failure observed in 15 of 32 knees (47%), was from medial tibial
collapse. Of those that failed by early medial collapse 87% were
The Rise an all polyethylene design and collapsed at a median of 16
Luke Austin, MD, Philadelphia, PA (n) months. 13 defects were treated with screws and cement or tibial
Raymond Ropiak, MD, Philadelphia, PA (n) augments while in 10 knees a tibial stem was implanted.
Manny D Porat, MD, Philadelphia, PA (n) Conclusions: There has been a diversity of reports of defects
Luis Pulido, MD, Philadelphia, PA (n) encountered in revision of UKA to TKA. All polyethylene
Javad Parvizi, MD, Philadelphia, PA (a – Stryker) components are thought to decrease poly wear and conserve
tibial bone by eliminating modularity and metal backing.
Eugene R Viscusi, MD, Philadelphia, PA (n)
Significant early medial tibial bone collapse is a surprising
Richard H Rothman, MD, Philadelphia, PA (e – Stryker) finding in predominately medial UKA’s with and all polyeth-
Abstract: There have been immense improvements in surgical ylene tibial components and represents a more challenging revi-
and anesthesia delivery of care for patients undergoing joint sion than for late aseptic loosening. Early failure may be related
arthroplasty. The use of intrathecal long acting opioids, as well to edge loading, component sizing and tibial slope, and excess
as improved nursing have prompted more strict postoperative stress concentration reported in FEA analyses of fixed bearing all
surveillance including monitoring of oxygen saturation. The poly designs. In our series, knees that failed by medial collapse
purpose of this prospective study was to evaluate the incidence required more complex reconstructions than previously
and the etiology of hypoxia following elective joint arthroplasty. reported in the literature.
1654 patients undergoing joint arthroplasty at this institution
were followed prospectively over 10 months. Patients presenting POSTER NO. P189
with hypoxia, being defined as oxygen saturation < 90% on
pulse oximetry, were identified. Detailed data on these patients
Sex-Based Differences in Total Knee Patient
were collected. Hypoxia occurred in 74 of 1654 patients (4.5%). Outcome
Serious etiology, defined as pulmonary embolism (11, 15%), Lynne C Jones, PhD, Baltimore, MD
pulmonary edema (15, 20%) and pneumonia (4, 6%), were (a – Stryker Howmedica, Zimmer)
identified in 30 of 74 patients (41%). Other causes of hypoxia Harpal Singh Khanuja, MD, Baltimore, MD (n)
included COPD (5, 6%), atelectasis (21, 29%), and undiagnosed Simon Mears, MD, Baltimore, MD (a – Zimmer)
(18, 24%). Strict postoperative surveillance of patients under-
Patricia Pietryak, RN, Baltimore, MD (n)
going total joint arthroplasty can lead to an epidemic of hypoxic
patients. Because of the medico-legal environment, majority of David S Hungerford, MD, Baltimore, MD
these patients are subjected to extensive medical work-up. It (c – Stryker Howmedica)
appears that a single episode of hypoxia, particularly when Marc Wilson Hungerford, MD, Baltimore, MD (e – Zimmer)
oxygen desaturation is not dramatic (<10%), may not be a clin- Abstract: There is a growing concern with whether the sex of the
ically significant event. Although close monitoring of all patients patient influences perioperative morbidity and outcomes. To

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

with hypoxia is warranted, only those with persistent or address this issue, we conducted a study of patients that have
dramatic oxygen desaturation may require further investigation. undergone total knee replacement and stratified the results
according to sex. Two hundred and twenty patients who under-
POSTER NO. P188 went primary total knee arthroplasty with an PCL-retaining total
An New Early Failure Mode of Unicompartmental knee prosthesis from July, 2001 to April, 2004 were included in
this study. There were 70 men with a mean age of 68 (range, 39-
Knee Arthroplasty 88). There were 150 women with a mean age of 66 (range, 31-
Thomas Joseph Aleto, Jr MD, Columbia, MO (n) 92). A complete medical history, physical examination, Knee
Michael E Berend, MD, Mooresville, IN (a, e – Biomet) Society Scores, and Quality of Life forms (WOMAC, SF-36) were
Merrill A Ritter, MD, Indianapolis, IN (a, e – Biomet) obtained for each of these patients preoperatively and at routine
Robert Michael Meneghini, MD, Indianapolis, IN post-operative visits. There have been no revisions in either
(a, e – Zimmer) patient group. With respect to Knee Society Scores, preoperative
Philip M Faris, MD, Mooresville, IN (a, e – Biomet) Function scores were significantly lower for females (42.2; 95%
confidence limits, 39.5 to 45.0) as compared to males (49.4;
Abstract: Introduction: Unicompartmental Knee Arthroplasty
95% CL, 45.3 to 53.5) (p=0.005), while KSS Knee scores were
(UKA) has enjoyed renewed interest in the U.S. with many new
not statistically significantly different between females (56.2;
fixed and mobile bearing designs. Polyethylene wear, progressive
95% CL, 53.7 to 58.7) and males (57.6; 95% CL, 53.9 to 61.2)
lateral OA, and component loosening are common mechanisms
(p=0.533). Postoperatively, females demonstrated significantly
of failure in the first and second decade following UKA. The
lower score for both parts of the KSS (Knee score, p=0.014;
purpose of this study is to describe an early and unreported
Function Score, p=0.034). For females, the mean postoperative
mechanism of failure of medial UKA resulting from significant
Knee Scores were 89.5 (95% CL, 87.9 to 91.1) and the Function
medial tibial bone collapse and describe the intraoperative find-
Scores were 64.8 (95% CL, 61.1 to 68.5). For men, the mean
ings, implant needs, defect management, and clinical outcome
postoperative Knee Scores were 93.1 (95% CL, 90.8 to 95.5) and
for a consecutive series of failed medial UKA’s revised to TKA.
the Function Scores were 71.9 (95% CL, 66.5 to 77.4). There
Materials and Methods: From 1992 to 2006, 32 consecutive revi-
were statistically significant differences between sexes in the
sions of UKA to TKA were performed. The clinical records and
Knee Society Scores both preoperatively (Function) and postop-
radiographs were reviewed determining time to failure and the
eratively (Knee, Function). The impact of these findings on the
mechanism of failure, which were correlated with implant
long-term follow-up of these patients remains to be determined.
design and implantation technique. Results: The mean time to
Different parameters need to be assessed to account for the
failure for the group was 5.6 yrs. KSS improved from 50 to 89
observed differences between the scores for females and males.
points postoperatively. 15 knees were revised to CR knees, 12 to

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
471
PPSE 07:Layout 1 1/12/07 1:41 PM Page 472

POSTER NO. P190 increased failure rates with high pressure (>360,000 P)
Blood Transfusion from Reinfusion Systems in TKA: (p<0.002) and knees in varus have a lower failure rate with lower
pressure. (p<0.04) For metal backed components with high
Comparison of Different Wound Drainage Techniques pressure and a tibial component alignment of varus > 4o a
Arno Martin, MD, Feldkrich, Austria (n) failure rate of 3.5 % was noted with a Hazard ratio of 20.4 times
Archibald von Strempel, MD (n) failure of low pressure knees. For all poly components with high
Abstract: The benefits of postoperative wound drainage in pressure calculations and any alignment the failure rate was
patients with total knee arthroplasty (TKA) with regards to 20.0% with a Hazard Ratio of 15.6. p<0.0001 Conclusions: We
mobilisation and wound healing were studied. We wanted to conclude that calculated tibial stress is a critical factor and
determine the efficacy of an autologous blood retransfusion explains why some well-aligned knees develop early loosening
system. 150 patients with TKA were divided into three groups of and how some knees implanted in varus survive. This calcula-
50 patients: A) Three wound drainages with an autotransfusion tion combines alignment, patient BMI, tibial component size
system and suction; B) no wound drainage; C) one intraarticular and area and how all of these factors relate to component loos-
wound drainage without suction. Haemoglobin values, blood ening in a multifactorial process. Pressure calculations correlated
transfusion requirements, blood loss, postoperative range of with RSA component migration data is currently underway.
motion, knee society score and rate of complications were
observed and recorded. All patients were operated without POSTER NO. P192
tourniques for lower blood loss during total knee replacement. Patient Satisfaction with Computer Navigation in
In the group of patients with wound drainage and a retransfu- Total Knee Arthroplasty Versus Standard Method
sion system the requirement of postoperative additional blood
transfusion was not significantly less than in the group without Yogeesh D Kamat, MS, DNB, Epsom, Surrey,
wound drainage. Group A had the most blood loss of all. The United Kingdom (n)
group without wound drainage had more haematoma and Ajeya R Adhikari, MBBS, Greater London, United Kingdom
wound healing complications. Best results were observed within (n)
the group with one intraarticular drainage without suction. The Pradeep Moonot, MRCS (n)
rate of complications was not increased and the blood transfu- Dan Matthews, MRCS (n)
sion requirements were the lowest. This study shows that total Abstract: Computer assisted knee arthroplasty has been shown
knee replacement involving one intraarticular wound drainage to result in better post-operative alignment of prostheses. Our
without suction attains the best results. During the last four years aim was to compare the patient satisfaction outcome using
we used this wound drainage technique in 787 TKAs and can Oxford knee scores (OKS) between computer assisted and
confirm all findings of this study. conventional knee replacement. We retrospectively collected
data of 299 total knee replacements carried out by a single
POSTER NO. P191 surgeon and have divided them according to use of: (1)
Calculated Tibial Stress: Why Well Aligned TKAs computer navigation- an imageless semi robotic system (Plus
Fail & Malaligned TKAs Survive Orthopedics, Switzerland) or (2) standard instrumentation.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

There were no significant differences in pre-operative Oxford

Michael E Berend, MD, Mooresville, IN (a, c, e – Biomet)
knee scores (OKS) and demographic data between the groups.
Merrill A Ritter, MD, Indianapolis, IN (a, e – Biomet) 139 patients had a one-year follow-up with 65 in group 1 and
John B. Meding, MD, Mooresville, IN (a, c, e – Biomet) 74 in group 2. Two year follow-up data was available for 50
E Michael Keating, MD, Mooresville, IN (a, c, e – Biomet) patients with 28 in group 1 and 22 in group 2 and a three year
Philip M Faris, MD, Mooresville, IN (a, c, e – Biomet) follow-up for 21 patients with 13 and 8 in groups 1 and 2 respec-
Robert Andrew Malinzak, MD, Mooresville, IN (a – Biomet) tively. The mean OKS at 1-year follow up was 24.95 (range 12-
Robert Michael Meneghini, MD, Indianapolis, IN 54, s.d. 9.8) for group 1 and 25.32 (range 12- 49, s.d. 9.7) for
(a – Biomet) group 2 (p= 0.41) Similarly at 2 years the mean OKS was 25.39
Jeffery L. Pierson, MD, Indianapolis, IN (range 13- 53, s.d. 10.3) for group 1 and 24.14 (range 12- 43, s.d.
9.1) for group 2 (p not significant). The result was similar for
(a – Biomet, e – Zimmer)
three-year follow up. This study revealed that computer assisted
Abstract: Introduction: Early loosening of TKR implants is a knee arthroplasty does not result in better patient satisfaction
multifactorial process associated with alignment, BMI, poly than standard instrumentation in the short-term follow up.
wear, loss of initial fixation, and medial bone overload. We have Long-term studies are necessary to show whether accurate align-
observed loosening in well-aligned knees and long-term survival ment of the implants will improve the patient satisfaction as it
of knees aligned in varus without understanding why. The increases survival of the arthroplasty.
purpose of this study was to quantify applied tibial stresses and
examine the role of increased stresses on implant loosening in a POSTER NO. P193
large series of cemented TKR’s with metal backed and all poly-
ethylene tibial components. Methods: 6024 cemented metal
Articulating Spacer Treatment for Infected Total
backed (MB) and 524 all-polyethylene (AP) AGC TKR’s (mean Knee Arthroplasty
f/u MB: 5.4 yrs; and AP: 7.3 yrs) performed for OA from 1983- John Anderson, MD, New York, NY (n)
2002 were examined with minimum 2 year f/u. We developed a David Mayman, MD, New York, NY (*)
new method to calculate tibial stresses by multiplying the Mathias P G Bostrom, MD, New York, NY (n)
patient’s mass by the acceleration constant due to gravity and
Thomas P Sculco, MD, New York, NY (n)
then dividing by the area of the tibial component. Tibial stress
and failure rates were correlated and Hazard ratios were calcu- Abstract: Two-stage re-implantation using cement antibiotic
lated by Cox Regression. Results: There were 22 MB failures and block spacers for infected total knee arthroplasty (TKA) is effec-
32 AP failures. Knees in neutral alignment had significantly tive treatment. However, the cement spacer allows only a very
limited range of knee movement during that period, resulting in

472 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 473

knee stiffness, pain, immobility (and its inherent sequelae) and POSTER NO. P195
bone loss. We believe that an articulating spacer that allows the Clinical, Radiographic and Retrieval Analysis of
patient to mobilize is effective in treating infection with fewer
immobility complications. This retrospective study analyzed 40 Failed PFC Total Knee Replacements
consecutive patients (40 knees) with chronic deep TKA infec- Ivan M Tomek, MD, Lebanon, NH (n)
tion. During 2003-4, patients underwent two-stage articulating John H Currier, MS, Hanover, NH (a – DePuy, Zimmer)
spacer surgery, involving the following: 1) the infected femoral Stephen R Kantor, MD, Lebanon, NH (n)
component was removed for only a short period (sufficient for Drew Crasper, BA, MHS (n)
it to be autoclaved) and then replaced; 2) the tibial component Lauren Carlson, MPH (n)
and polyethylene are totally removed and replaced with a “half-
Michael B Mayor, MD, Lebanon, NH (a, e – DePuy, Zimmer)
spacer”; 3) post-operatively, the patient is encouraged to mobi-
lize as much as tolerated.; and 4), after a period of tailored Abstract: Between 1993 and 1997, 677 Press Fit Condylar total
intravenous antibiotic therapy and negative culture growth, new knee replacements were implanted at our institution. To date, 82
femoral and tibial components are fixed. All patients were have been revised, representing a failure rate of 12.2 percent at a
assessed in the office at a minimum of two years and Knee mean of 6.9 years. The purpose of the present study was to retro-
Society scores calculated. The re-infection rate was 10% (4 spectively review all known failures, their clinical history, radi-
patients). The Knee Society knee and function scores before and ographic assessment and retrieval analysis. Radiographs were
after surgery improved from 65 to 87 and 55 to 75, respectively. scored according to the Knee Society criteria, and alignment,
The average range of motion improved from 3-93 degrees to 2- lucencies or osteolytic regions were measured. All clinical
106 degrees. A two-stage re-implantation technique that utilizes records were reviewed and variables recorded including age,
an articulating spacer for infected TKA, results in effective eradi- gender, BMI, pre-operative diagnosis and reason for failure.
cation of infection and improves patient mobility. Retrieval analysis and damage scoring was performed according
to accepted methodology and measurements quantifying back-
POSTER NO. P194 side wear were carried out. Shelf life prior to implantation was
obtained from the manufacturer. There were 49 males and 33
A Prospective Comparison of Ceramic and Oxinium females with a mean age of 60.8 years and BMI of 29.7 at index
TKA Components in Metal Hypersensitivity Patients surgery. Polyethylene processing was gamma-in-air and shelf life
Sam Nasser, MD, Belleville, MI (e – Smith and Nephew) averaged 17.6 months before implantation. The average femoral
Michael P Mott, MD, Warren, MI (n) alignment was 96 degrees and tibial alignment was 87 degrees.
Paul H Wooley, PhD, Detroit, MI (n) The revising surgeons characterized osteolysis as severe in 18
knees, moderately severe in 9, moderate in 8, and mild in 7
Abstract: Hypersensitivity to metals has been identified as a
knees. Reason for revision was aseptic loosening in 36 TKAs,
possible cause of arthroplasty failure. Hypoallergenic ceramics
polyethylene wear without loosening in 10, synovitis and pain in
have been recommended as an alternative, but their cost and
9, infection in 8 and failure for other reasons in 15. Radiographs
material properties have restricted these applications. The metal-
were reviewed in 61 of 82 failed TKAs, and showed progressive
loceramic composite Oxinium has been suggested as another
lucencies around 40 implants. Retrieval analysis of available

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

alternative. This prospective study compares these materials in
components demonstrated significant articular surface wear and
patients with metal hypersensitivity documented by skin patch
backside volumetric wear averaging 1048 mm3. Review of PFC
and in vitro leukocyte stimulation testing. Forty-four patients
total knee replacements implanted between 1993 and 1997
(39 women, 5 men) underwent 51 primary TKA, and 14 (12
demonstrated a failure rate of 12 percent at a mean follow-up of
women, 2 men) underwent 16 revision TKA using either ceramic
83.2 months, with aseptic loosening and associated osteolysis as
femoral components (10 primary, 6 revisions) or Oxinium
the main reason for failure. Retrieval analysis showed significant
femoral components (42 primary, 9 revisions). Tibial compo-
volumetric wear on the backside of tibial polyethylene liners.
nents varied, approximately half being all-polyethylene. All
components were fixed with acrylic cement. No patients in the POSTER NO. P196
primary groups developed allergic reaction symptoms at a
minimum of two years following surgery (34-130 months, Computer-Assisted Navigated Systems Have a
average: 50 months). Serial postoperative serum antibody and Valuable Teaching Role in Total Knee Arthroplasty
leukocyte studies have shown no reaction following placement John Dillon, MRCS, Glasgow, United Kingdom (n)
of either type of knee. Those undergoing revision had rapid reso- Frederic Picard, MD, Glasgow, United Kingdom (n)
lution of preoperative symptoms of pain, effusion and eczema-
Abstract: Computer-assisted navigated techniques have become
tous rash. Serum studies showed a concomitant fall in antibody
incorporated into routine total knee arthroplasty since its advent
levels. Two patients who had undergone revision TKA with
in 1997. It has been shown that resultant alignment of the
alumina implants subsequently underwent second revisions
component prostheses is more reproducibly accurate, making
(both at 9 years) using Oxinium femoral implants. Neither
malalignment less likely. Furthermore, it has been suggested that
developed adverse clinical symptoms or changes in antibody
computer-assisted navigation systems may have a valuable role
profile. While this study is relatively small, it is the only inde-
in teaching. The aim of this study was to compare levels of
pendent, prospective comparison of these materials. The results
understanding of the fundamentals in alignment of a total knee
suggest Oxinium offers the same hypoallergenic properties of
prosthesis in centers where computer-assisted navigation
ceramics without their adverse material properties, and at a
systems were routinely in use, compared to those where it was
substantially lower cost.
unavailable. A questionnaire was given to 62 trainees
throughout Scotland in an exam-type format. The questionnaire
showed a long-leg film of a left lower limb in a patient with
medial compartment osteoarthritis. Each trainee was asked to
plot the mechanical axis of the lower limb, the mechanical
femoro-tibial angle, and their relevant experience in computer-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
473
PPSE 07:Layout 1 1/12/07 1:41 PM Page 474

assisted techniques. A questionnaire was given to 62 trainees we used direct compression molded 1900H tibial inserts
throughout Scotland in an exam-type format. The questionnaire (Biomet Inc). Radiation sterilization was 3.2-Mrad under argon
showed a long-leg film of a left lower limb in a patient with atmosphere and there was no subsequent treatment. Test inserts
medial compartment osteoarthritis. Each trainee was asked to were GUR1050 molded UHMWPE inserts. The direct compres-
plot the mechanical axis of the lower limb, the mechanical sion molded GUR1050 tibial inserts were processed identically
femoro-tibial angle, and their relevant experience in computer- to ArCom inserts. Knee simulation was conducted on a 6 station
assisted techniques. Computer-assisted navigated systems simulator. Lubricant was serum (20mg/ml protein) with addi-
appear to have a valuable teaching role in TKR. tive EDTA. Wear was measured gravimetrically. Microscopic
characterization was carried out on the polyethylene tibial
POSTER NO. P197 inserts using confocal Raman microprobe spectroscopy (irradia-
In Vitro Patellofemoral Kinematics and Forces in tion with a blue laser with wavelength 488 nm) at end of study.
The wear showed uniform linear trending (regression coeffi-
Unicompartmental and Total Knee Arthroplasty cients > 0.95). Wear of the control implants (CoCr / 1900H)
Andrew J Price, FRCS, Oxford, United Kingdom (n) averaged 3.6 mm3/Mc with good control of experimental vari-
David J Beard, DPhil, Oxford, United Kingdom (n) ance. Wear of the GUR1050 implants (CoCr / GUR1050) aver-
Hemant G Pandit, FRCS, Oxford, United Kingdom (n) aged 3.4 mm3/Mc, also with good control of experimental
Harinderjit Singh Gill, PHD, Oxford, United Kingdom (n) variance. GUR1050 was equivalent to 1900H. The molded
Christopher A F Dodd, FRCS, Oxford, United Kingdom (n) 1900H has been very successful in TKR and thus our current
David W Murray, MD, Oxford, United Kingdom (n) knee study suggests that the molded GUR1050 will also provide
excellent results.
Paul T Oppold, Florham Park, NJ (n)
Amy Zavatsky, Oxford, United Kingdom (n) POSTER NO. P199
Abstract: Implantation of UKA and TKA modify the joint surfaces
and ligamentous restraints in different ways and their effects on
In Vivo Performance of VersaBond Bone Cement in
patellar function might be expected to differ. The aim of this Total Knee Arthroplasty using RSA
study was to quantify any such differences by measuring simul- Doug Naudie, MD, London, Canada
taneously tibiofemoral kinematics and patellofemoral (PF) kine- (a, b – Smith & Nephew, a – Depuy)
matics and forces in vitro in knee joints both before and after Xunhua Yuan, Lund, Sweden (a, e – Smith & Nephew)
UKA and TKA. Eleven cadaveric knees were tested in a leg-exten-
Juliana Marr, RN, London, Canada (*)
sion rig. Extension was achieved by applying quadriceps force,
Richard W McCalden, MD, London, Canada
force transducers recorded quadriceps force (QF) and PF contact
force (PFCF). Kinematics were recorded with a 3D optoelectronic (a, b – Smith & Nephew, a – Depuy)
tracking system. Three conditions were tested: intact knee, medial Steven J MacDonald, MD, London, Canada
UKA (Oxford UKA), PCL-retaining TKA (AGC). There were no (a, b – Smith & Nephew, a, e – Depuy)
significant changes in PF kinematics and forces after UKA. TKA Cecil H Rorabeck, MD, London, Canada
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

lead to a significant increase in abduction and relative tibio- (a, b, e – Smith & Nephew, a – Depuy)
femoral position over the flexion range. In addition patellar tilt David W Holdsworth, London, Canada (*)
and spin were abnormal. The patella displayed jumps in position Robert Barry Bourne, MD, London, Canada
at approximately 60° of knee flexion, which corresponded to
(a, b, e – Smith & Nephew, a – Depuy)
sudden changes in the point of application of the PFCF on the
Abstract: VersaBond® is a newly introduced bone cement for use
patella; this was associated with sudden changes in QF required
in total joint arthroplasty designed to optimize the properties
to extend the knee. Minimal changes to knee kinematics and
and characteristics for vacuum mixing. Previous studies have
patellofemoral forces were caused by the UKA design. The TKA
emphasized the need for the stepwise introduction of new bone
had a much greater effect on knee function, highlighted by
cements in randomized studies using RadioStereometric
abnormal patellar tracking and changes in PF forces. The findings
Analysis (RSA) before being launched for general use. The
may explain the low incidence of PFJ problems reported
purpose of this study was to evaluate using RSA the in vivo
following UKA, in sharp contrast to TKA.
performance of VersaBond® in achieving component fixation in
POSTER NO. P198 total knee arthroplasty. It was our hypothesis that VersaBond®
offers comparable implant fixation to Simplex® and Palacos®
Molded GUR1050 Resin Type Performance in Knee bone cements, both of which have demonstrated a successful
Wear Simulation clinical track record for over 20 years. A prospective, double-
Riichiro Tsukamoto, Loma Linda, CA (n) blinded randomized clinical trial was designed and performed.
Mikiko Tsukamoto, MD (n) 36 patients requiring primary cemented total knee arthroplasty
were randomly assigned to receive Simplex®, Palacos®, or
Hiromu Shoji, MD, Riverside, CA (n)
VersaBond®. All patients received the same surgical protocol and
Giuseppe Pezzotti, PhD (n) the same post-operative care. All patients had RSA radiographic
Ian C Clarke PhD, Loma Linda, CA (a – Biomet) examinations post-operatively and at 3, 6, 12, and 24 months.
Abstract: There are now clinical reports in the USA with over Tibial component migration using RSA was used as the primary
95% good clinical results were found with 15 years follow-up of outcome measure while Knee Society Clinical Rating Scores,
the AGC Knee and its molded tibial inserts [3-5]. With the WOMAC, and SF12 were used as secondary outcome measures.
1900H resin no longer commercially available, the alternative At 6 weeks, we found a statistically significant difference in varus-
polyethylene appears to be the molded high molecular weight valgus tilt with VersaBond® cement (ANOVA p=0.032). Over the
GUR1050 resin. Therefore the aim of this study was to compare next 24 months, we did not find any statistical differences in
wear of the new alternative GUR1050 resin versus the control varus-valgus tilt, internal-external rotation, or anterior-posterior
1900H inserts run against CoCr femoral implants. As controls, tilt between the three bone cements. We found a statistically

474 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 475

different increase in resultant mean three dimensional transla- component and host bone. The purpose of this study was to
tional movement with VersaBond® at 6 months (p=0.032), 1 assess the early results of trabecular metal for non-cemented
year (p=0.029), and 2 years (ANOVA p=0.038). There were no fixation of the tibial baseplate in primary TKA. Between
statistical differences in clinical outcome scores between the December 2001 and November 2003, 42 TKAs were performed
three bone cements and no clinical failures requiring revision. in 39 patients utilizing trabecular metal for fixation of the tibial
RSA can be used at one or two years to identify total knee pros- baseplate (Zimmer, Warsaw, IN). There were 36 (92%) females
theses at risk of clinical loosening and revision with a predictive and 3 (8%) males which included 20 (51%) left, 16 (41%) right,
power of 85%. Although no clinical failures were observed, the and 3 (8%) bilateral cases. The Knee Society scoring system
increased mean total three dimensional translation observed (KSS) was used to assess patients pre-operatively and post-oper-
with VersaBond® bone cement raises concerns about its in vivo atively at 6 weeks, 3, 6, 12, and 24 months. Anterior-posterior
performance over time. and lateral radiographs were digitized and independently
assessed for component position, radiolucencies, gaps between
POSTER NO. P200 the component and host bone and evidence of bone changes
Factors Contributing to Failures of Two Stage due to component loading in compression. The average recent
follow-up was 25.3 months. The average total KSS improved
Procedures for Infected Total Knee Arthroplasty from 91.1 ±25.3 (pain: 11.8, knee: 46.2, function: 33.1) pre-
Jay Michael Zampini, MD, Ardmore, PA (n) operatively to an average of 106.2 ±23.9 (pain: 32.1, knee: 47.0,
Gwo-Chin Lee, MD, Horsham, PA (n) function: 27.2) at 6 weeks and 144.6 ±23.0 (pain: 43.3, knee:
Abstract: Two stage reimplantation procedures have become the 48.9, function: 52.3) at 24 months. The average KSS pain
gold standard for treatment of chronically infected total knee component increased to 32.1 at 6 weeks and remained below 40
replacements. Despite of improvements in surgical and antimi- until the 12-month follow-up (42.4). There was one early revi-
crobial therapies, failure rates of up to 25% have been reported. sion due to fracture of the medial aspect of the tibia from
The purpose of this study is to evaluate the factors leading to notching of the tibial cortex during peg preparation in a patient
failure of two stage procedures for infected TKR. Ten failed two with a BMI of 52. The tibial component has since been
stage reimplantation procedures were performed at our institu- redesigned with placement of tibial anchor pegs more centrally
tion for chronic deep knee infections. There were 6 men and 4 located to avoid this problem. In conclusion the use of trabec-
women with a mean age of 54 years. Each patient underwent ular metal for fixation of the tibial baseplate in TKA yields
resection arthroplasty with placement of an antibiotic cement predictable and satisfactory short-term clinical and radiographic
spacer. Culture specific and organism sensitive antibiotics were results. Early post-operative pain not generally seen in cemented
administered intravenously for a minimum of nine weeks TKA may be related to evidence of progressive radiographic fixa-
followed by reimplantation. The results were compared to a tion and seems to resolve between 6 and 12-months.
group of patients with infected TKRs who were successfully
treated with a 2 stage procedure. The median number of POSTER NO. P202
surgeries prior to formal 2 stage exchange was 3 procedures. The Analysis of Modes of Failure of Primary Total Knee
most common infecting organism was methicillin resistant
Arthroplasties over the Past 25 Years

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Staphylococcus aureus (n=4), MSSA (n=2), Streptococcus (n=2),
and polymicrobial (n=2). The average time to reinfection was 8 Lipalo Mokete, MD, London, Canada
months. Review of radiographs revealed retained cement (a – Smith & Nephew)
following initial resection in six cases. Despite multiple proce- Doug Naudie, MD, London, Canada
dures, 3 knees continued to have persistent infections leading to (a – Smith & Nephew, Depuy)
knee arthrodesis; one eventually requiring transfemoral ampu- Jeffrey Guerin, London, Canada
tation. Retained cement was a leading cause of failure of 2-stage (a – Smith & Nephew, Depuy)
procedures for treatment of deep prosthetic knee infections.
Robert Barry Bourne, MD, London, Canada
Other causes include prior multiple surgeries and polymicrobial
(a, e – Smith & Nephew, a – Depuy)
infections.
Abstract: The indications for reoperations in primary total knee
POSTER NO. P201 arthroplasty over the years shows that there has been a change in
the relative importance of the different modes of failure. We felt
Trabecular Metal Tibial Baseplate in Non- that a long-term review of modes of primary knee arthroplasty
Cemented, Primary TKA: A Minimum 2-Year Study failure from a single academic institution would allow us to
Audrey K Tsao, MD, Sun City West, AZ (a, b, e – Zimmer) identify common trends and form the basis for future projec-
Joseph D Delaski, Resarch, MBA, Jackson, MS tions. It was our hypothesis that the impact of advances made
(e – University Mississippi Medical Center) since the introduction of contemporary knee arthroplasty
designs should manifest themselves in a reduction in early fail-
Robert W Eberle, Apex, NC (e – Zimmer)
ures over time. Continous follow-up of total knee replacement
Abstract: The initial use of non-cemented fixation of the tibial patients has been a goal at our joint replacement unit since 1981.
baseplate in total knee arthroplasty (TKA) led to mixed and Using our computerized joint arthroplasty database, we retro-
unpredictable results. Thereafter, cemented fixation of the tibial spectively studied the modes of failure of contemporary primary
baseplate in TKA became the ‘gold-standard.’ Cement is used as total knee arthroplasties in a single teaching institution over a 25
a component-to-bone bonding agent and as filler for voids and year period (1981 - 2005). Only patients in whom the first reop-
irregularities in the prepared host bone. The introduction of eration of the primary arthroplasty done at our institution were
trabecular metal for non-cemented fixation in total joint arthro- included in the study. Revision was defined as any procedure
plasty has shown excellent potential. Recent reports of the use of entailing removal, exchange or addition of prosthesis to the
trabecular metal for acetabular component fixation in total hip operated knee. Analysis was divided into five groupings of five
arthroplasty (THA) have radiographically shown optimum fixa- years each. 537 knees in 475 patients were identified. The
tion qualities and the promotion of gap filling between the predominant mode of failure for the first two year groupings

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
475
PPSE 07:Layout 1 1/12/07 1:41 PM Page 476

(1981-1985, 1986-1990) was aseptic loosening. From 1991- mediolateral dimensions of the distal femur and proximal tibia.
1995, the predominant mode of failure was extensor mecha- The measurements were compared with the dimensions of the
nism and patellar complications. For the last two groupings prostheses of 5 current TKA systems. Asian femurs above ‘1 stan-
(1996-2000, 2001-2005), polyethylene wear was identified as dard deviation(SD) in anteroposterior dimension had wider
the primary mode of failure. The leading cause of early failures mediolateral dimension than femoral prostheses, which predis-
(within two years of index arthroplasty) was aseptic loosening poses to undercoverage. However, small femurs below ‘1SD had
from 1981-1990 and infection from 1991-2005. The average narrower mediolateral dimension than femoral prostheses,
time period between index arthroplasty and reoperation predisposing to mediolateral overhang. Asian tibiae had shorter
increased steadily from 3.8 years between 1981-1985 to 8.9 years lateral anteroposterior dimension than tibial prostheses predis-
between 2001-2005. Polyethylene wear and osteolysis have posing to posterolateral overhang or mediolateral undercov-
emerged as the dominant modes of late failure of primary total erage. The dimension and distribution of the Asian knees are
knee arthroplasty. Over the last fifteen years, infection has identified in this study. Currently available total knees does not
remained the dominant mode of early failure. Future research seem to be Asian friendly that the future total knee prostheses
should continue to focus on design modifications and tech- need to be modified for better fit to Asian knees.
niques to reduce late wear related failures.
POSTER NO. P205
POSTER NO. P203 ◆Focal Anatomic Resurfacing of the Femoral
The Fate of the Unexpected Positive Intraoperative Condyle: Preliminary Results
Culture Following Revision TKA Anthony Alberto Schepsis, MD, Boston, MA (a)
Ajay Aggarwal, MD, Columbia, MO (n) John William Uribe, MD, Coral Gables, FL (a)
Robert Stephen Burnett, MD FRCSC, Saint Louis, MO (n) Annunziato Amendola, MD, Iowa City, IA (a)
John C Clohisy, MD, Saint Louis, MO (n) Joshua A Siegel, MD, Exeter, NH (a)
Morris Kelly, BA, Saint Louis, MO (n) Frederick C Flandry, MD, Columbus, GA (a)
Shane T Fejfar, MD, Wichita, KS (n) Robert Buonnano, MD (a)
Robert L Barrack, MD, Saint Louis, MO (n) Robert B. Litchfield, MD, London, ON Canada (a)
Abstract: A study was undertaken to determine the incidence of Anthony Miniaci, MD,FRCSC, Cleveland, OH (a)
unexpected positive intraoperative cultures (PIOC) at the time of Abstract: Treatment of full thickness femoral condyle cartilage
revision total knee arthroplasty (TKA) and the subsequent lesions in middle-aged patients remains challenging since
results of selective treatment of patients in this clinical scenario. biologic treatment options have demonstrated less favorable
Eight hundred and eighty-nine TKA’s were performed during a results. A novel femoral resurfacing system allows for intraoper-
seven year period at three total joint referral centers. One ative mapping of the joint geometry and placement of a
hundred and ninety-seven were classified as infected and six matched contoured articular prosthetic (HemiCAP®). 32
hundred and ninety-two were classified as not infected based on patients (22 male, 10 female), mean age of 47 years (31-67),
established clinical and laboratory criteria and treated with revi-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

were included in this study. No additional cartilage defects

sion TKA. Of the knees classified as not infected, a PIOC (greater than grade 2) were allowed; no malalignment of > 7
occurred after revision TKA in thirty-seven of six hundred and degrees was allowed. BMI was set at < 30kg/m2. WOMAC scores
ninety-two (5.3 %) cases. Of PIOC in this group, twenty-eight of were collected preoperatively and at 3, 6, 12, and 24 months
thirty-seven (76%) were classified as false positive based upon postoperatively. Radiographic evaluation was conducted by an
the absence of any other evidence of infection and growth in independent radiologist. 30 patients were treated on the medial
broth only or growth quantified as rare on solid media and no femoral condyle, 2 on the lateral. Average follow-up to date is 11
further treatment was administered. Nine of thirty-seven (24%) months (3-24). Follow-up distribution: 2 patients at 2 years, 15
were classified as possible occult infections based on other labo- patients at 1 year; 5 patients at 6 months, 1 patient at 3 months,
ratory evidence of possible infection and growth on solid media and 9 patients are scheduled for their first postoperative scoring
quantified as more than rare or more than one positive culture. at 3 months. The average baseline WOMAC score for pain was
These patients were treated with six weeks of intravenous antibi- 312, stiffness 140, function 1086 and Global score 1538. At last
otics alone. The twenty-eight patients with unexpected PIOC follow-up the average pain subscore was 41 (87% improve-
were followed clinically for a minimum of two years (range 2-8 ment), stiffness was 37 (72% improvement), the function was
years) during which time no patient developed clinical signs of 162 (84% improvement) and the Global WOMAC score was
infection or underwent further surgery. A positive intraop culture 253 (83% improvement). Radiographic evaluation did not
in the absence of other evidence of infection should not be taken reveal any signs of device migration or radiolucency around the
as definitive evidence of infection and does not require further fixation and articular component. The HemiCAP® system is joint
treatment. preserving through minimal removal of bone and conservation
of healthy cartilage. Short-term results demonstrate excellent
POSTER NO. P204 pain relief and functional improvement.
Anthropometric Analyses of the Asian Knees: A
Comparison with Prostheses of 5 Total Knee Systems
Chul Won Ha, MD, Seoul, Republic of Korea (n)
Moon-Jong Chang, MD (n)
Jun-Suk Moon (n)
Abstract: This study is to establish a detailed anthropometric
data of Far East Asian knees and compare the data with current
total knee prostheses. 400 consecutive osteoarthritic knees were
measured intraoperatively regarding the anteroposterior and

476 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 477

POSTER NO. ORS 2 photorealistically allowing visual comparisons of the different

Development of an In-Vivo Technique for designs for each loading condition. Each design handled the
demands of high flexion activities in a different manner. Total
Determination of 3D Kinematics of the Patello- contact areas varied between 207mm2 and 831mm2 with peak
Femoral and Tibio-Femoral Joint in Patients with contact stress varying between 7.7MPa and 42.0MPa. Femoral
TKA Pre- and Postoperatively cam engagement in the posterior stabilized designs promoted
load sharing between the central post and the posterior medial
Ruediger M von Eisenhart-Rothe, MD, MBA, Schwandorf, and lateral compartments of the tibial plateau. The results of this
Germany (a – DFG, Klein-Stiftung) study demonstrate that high flexion activities are very
Karl-Hans Englmeier, PhD, Munich, Germany (n) demanding and cause large stresses to develop in the posterior
Thomas Vogl, MD, Frankfurt, Germany (n) tibial plateau regions exceeding the 20 MPa yield strength of the
Heiko Graichen, MD, Schwandorf, Germany UHMWPE material. This increases the likelihood of early
(a – DFG, Klein-Stiftung) polymer damage and suggests that design conformities which
Aim was to develop an in vivo technique which allows determi- avoid line contact at these increased flexion angles are needed to
nation of femoro-tibial and of femoro-patellar 3D-kinematics in ensure component longevity.
TKA simultaneously. The knees of 20 healthy volunteers and of
8 patients with TKA (PCR, rotating platform) were investigated. SCIENTIFIC EXHIBIT NO. SE18
Kinematics analysis was performed in an open MR-system at Hemostasis in Primary Unilateral Knee Arthroplasty
different flexion angles with external loads being applied. The Using a Bipolar Sealer
TKA components were identified using a 3D-fitting technique,
Viktor Erik Krebs, MD, Rocky River, OH
which allows an automated 3D-3D-registration of the TKA.
Femoro-patellar and femoro-tibial 3D-kinematics were analyzed (a – Tissue Link, a, e – Stryker)
by image postprocessing. The validity of the postprocessing tech- Michael A Mont, MD, Baltimore, MD
nique demonstrated a coefficient of determination of 0.98 for (a – Tissue Link, c – Stryker)
translation and of 0.97 for rotation. The reproducibility yielded German A Marulanda, MD, Baltimore, MD (n)
a coefficient of variation (CV%) for patella kinematics between Benjamin E Bierbaum, MD, Boston, MA (e – Stryker)
0.17 % (patello-femoral angle) and 6.8 % (patella tilt). The Victor Goldberg, MD, Cleveland, OH
femoro-tibial displacement also showed a high reproducibility (a – Tissue Link, e – Zimmer)
with CV% of 4.0 % for translation and of 7.1 % for rotation. Michael D Ries, MD, San Francisco, CA (e – Tissue Link)
While in the healthy knees the typical screw-home mechanism
Oscar David Taunton, Jr, MD, Grapevine, TX
was observed, a paradoxical anterior translation of the femur
relative to the tibia combined with an external rotation occurred (b, d, e – Tissue Link)
after TKA. 50 % of the TKA`s experienced a condylar lift off of > Aaron Glen Rosenberg, MD, Chicago, IL
1mm. Regarding patellar kinematics significant changes were (e – Tissue Link, a, c, e – Zimmer)
found in both planes in TKA. The results demonstrate that the Several studies of major orthopaedic surgical procedures such as

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

presented 3D MR-open based method is highly reproducible total knee arthroplasties (TKA) have shown significant amounts
and valid for image acquisition and postprocessing and provides of intraoperative and postoperative blood loss. As a result, blood
– for the first time - in vivo data of 3D kinematics of the tibio- management strategies have been proposed to reduce the risk for
femoral and simultaneously of the patello-femoral joint during postoperative blood transfusions. Methods to control blood loss
knee flexion. in TKA include electrocautery, tourniquet use, cemented implant
fixation, and minimally invasive surgery. A bipolar sealer device,
which combines radiofrequency energy with saline, has been
SCIENTIFIC EXHIBITS shown to reduce blood loss by hemostatically sealing soft tissue
and cut bone without the deleterious effects of high tissue
temperatures. The purpose of this study was to evaluate the effi-
SCIENTIFIC EXHIBIT NO. SE17 cacy of this device in total knee arthroplasty. Sixty-eight patients
requiring TKA for the treatment of end stage osteoarthritis of the
High Flexion in Contemporary Total Knee Design: A knee where prospectively enrolled, in a controlled, randomized,
Precursor of UHMWPE Damage? A Finite Element multicenter study. Thirty-five patients were randomized to the
Study treatment group (bipolar sealer device) and 34 patients to the
control group (conventional electrocautery). The primary
Edward Morra, MSME, Cleveland, OH (n) outcome variable was the difference in total blood loss between
A Seth Greenwald, DPhil Oxon, Cleveland, OH (n) these two groups of patients. The clinical evaluations were
The success of total knee arthroplasty has contributed to its performed pre and postoperatively using the Knee Society score.
worldwide expansion to Middle Eastern and Asian patient popu- Although the primary purpose of the study was to determine the
lations, where the attainment of high knee joint flexion is often perioperative clinical efficacy of the bipolar sealer (no long-term
a cultural requirement. This study investigates the tibial plateau follow-up) a decision was made to report any possible adverse
stresses that occur during high flexion activities in four contem- effect or medical treatment required within a three-month time
porary total knee designs. A three-dimensional, finite element frame. Chi-square tests were conducted for the analysis of cate-
model was created for each design studied from physical meas- gorical variables in the treatment groups. Student’s t-test and
urements of sterile, implantable quality production parts. analysis of variance (ANOVA) were used for the comparison of
Loading conditions for the more demanding high flexion activ- continuous variables. The variables associated with the primary
ities of stair ascent (60°), chair rise (90°) and kneel rise (135°) outcome measure (such as unadjusted and adjusted blood loss,
were simulated. Contact areas and stresses on the tibial insert number of transfusions, and hemoglobin decrease) were tested
were calculated and their magnitudes and locations imaged at a significance level of 0.05 with a 1-tailed alternative hypoth-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
477
PPSE 07:Layout 1 1/12/07 1:41 PM Page 478

esis. A strict intraoperative treatment algorythm was followed in during the pie-crusting of the iliotibial bend: hence, use of elec-
all cases. There were no significant demographic differences trocautery is recommended during the release of postero-lateral
between the two groups. The mean unadjusted blood loss for the capsule. Special attention must be taken in patients with small
bipolar sealer group was 1,254ml ± 543 ml versus. a mean of diameter of tibial plateau.
1,553ml ± 704 ml for the standard electrocautery group. The
mean adjusted blood loss for the bipolar sealer group was 1,686 SCIENTIFIC EXHIBIT NO. SE20
ml ± 1,081 mL versus. a mean of 2,447ml ± 1,425 ml for the Diagnosing Total Joint Arthroplasty Infections:
control group. The two variables achieved statistical significance
with a p=0.026 and p=0.007 respectively. The bipolar sealer
A Standardized Protocol
group presented a significantly lower drop in hemoglobin David R Marker, BS, Baltimore, MD (n)
(2.9g/dl ± 1.2 g/dl versus 3.5g/dl ± 1.3 g/dl; p = 0.042). The Johannes F Plate, BS, Heidelberg, Germany (n)
overall transfusion rate was 29% in the bipolar sealer group Thorsten M Seyler, MD, Baltimore, MD (n)
versus 47% in the control group. The prevalence of autologous German A Marulanda, MD, Baltimore, MD (n)
blood transfusions was 11% compared to 35% in the control Ronald Emilio Delanois, MD, Lutherville, MD (n)
group (p = 0.019). There was no significant difference in the Michael A Mont, MD, Baltimore, MD
Knee Society scores between the two groups at latest follow-up.
(e – Stryker Orthopaedics, Wright Medical Technology)
The bipolar sealer device achieved hemostasis without
producing smoke or charring the bleeding tissue. None of the Periprosthetic infections have been significantly reduced with
adverse events were related to the devices. The use of the bipolar the administration of modern prophylactic antibiotics and stan-
sealer during TKA significantly reduced blood loss, postoperative dard intra- and postoperative precautions. However, deep joint
drop in hemoglobin, and the need for autologous blood trans- infections still occur in approximately 1 to 5% of total knee
fusions without affecting the clinical outcome of the procedure. arthroplasties. Affected patients are at risk for prolonged pain
The investigators believe that the lower tissue temperatures and loss of functionality. It is essential that surgeons diagnose
produced by the bipolar sealer (with the consequent reduction infections both quickly and accurately; yet, there is currently no
in bone and soft tissue charring and the absence of smoke) consensus or standard protocol for diagnosis. This exhibit pres-
further support the use of the device in total knee arthroplasty. ents an analysis of four common modalities for diagnosing deep
joint infections: 1) clinical and radiographical presentations, 2)
SCIENTIFIC EXHIBIT NO. SE19 gram stains, 3) cultures from multiple mediums, and 4) frozen
sections. Between May 1996 and May 2006, multiple clinical
The Risk of Peroneal Nerve Injury Using the Inside- parameters and results were collected for the diagnosis of infec-
Out Technique for Valgus Deformity in TKA tions in total knee and hip arthroplasties. All diagnosis began
Roberto Rossi, MD, Turin, Italy (n) with an initial clinical assessment. The key clinical indicators for
Matteo Bruzzone, MD, Torino, Italy (n) infection included wound drainage, erythema, previous infec-
tion, ESR > 30mm/hr, CRP > 10mg/l, fever, pain, swelling, WBC
Federico Dettoni, MD, Turin, Italy (n)
> 11x10^9 per liter, radiographic indication of prosthetic loos-
Paolo Rossi, Torino, Italy (n),
ening, and the presence of one or more risk factors, such as
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

Amar S Ranawat, MD, New York, diabetes, inflammatory arthritis, sickle cell disease, HIV, and
NY (e – DePuy, Stryker Howmedica) immuno-suppressive therapy. Following clinical indications,
Filippo Castoldi, MD, Torino, Italy (n) gram stains were the first level of pathological testing for infec-
The inside-out technique of releasing the lateral structures of the tion. All gram stains were followed by cultures testing for organ-
knee to correct valgus deformities in total knee arthroplasty is isms. If patients required irrigation/debridement and revision,
recently been described in the literature. Concern has been frozen sections were used as another diagnostic tool. In all cases,
expressed over the use of this technique which may place the intra-operative would cultures were used as the gold standard for
common peroneal nerve (CPN) at risk for direct injury. The identifying infections. The effectiveness of the different diag-
objectives of our cadaveric study are to define the three-dimen- nostic tests was evaluated using the associated sensitivity, speci-
sional anatomy of the CPN in relation to the capsular structures, ficity, accuracy, predictive value for a positive test, and predictive
and to identify an anatomic landmark on the cut tibial surface value for a negative test. Overall, the gram stains showed varying
to help in the mapping of the location of the nerve during the sensitivities depending on the medium: 100% for blood, 32%
lateral soft tissue release. Twenty fresh cadaver knees (10 for joint aspirations, 25% for drainage, and 18% for operative-
cadavers: 8 female, 2 male) were used for testing. Knee replace- site samples. Clinical symptoms and risk factors were utilized to
ment surgery was performed using a posterior-stabilized, fixed- assess the need for infection testing using intra-articular joint
bearing total knee system and the common peroneal nerve aspirations. For aspirations, the sensitivity was 87%, specificity
identified. The distance from the postero-lateral corner of the 73%, accuracy 83%, predictive value for positive test 91%, and
tibia to the closest margin of the nerve (PLCN) was measured predictive value for negative test 62%. When compared to the
and correlated with measurements of the cut tibial surface in the aspiration sensitivity, the results for frozen sections were lower.
medial-lateral (ML), the anterior-posterior (AP) and the diag- With a positive diagnosis defined as a polymorph count of 5 or
onal (DG) planes as well as to the distance from the postero- more, the results showed 78% sensitivity, 54% specificity, 62%
lateral corner to the postero-lateral cortex of the fibular head accuracy, 48% predictive value for positive test, and 82% predic-
(PLCF) The PLCN was 13.54mm. (range: 11.20 to 18.60mm; SD tive value for negative test. The results of this study suggest that
2.204). The distance from the bone to the nerve was strongly gram stains, especially the results from the operative-site and
correlated to the PLCF distance (Pearson correlation coefficient drainage, are poor and should not be used as part of a standard
0.928, P<0.01), as well as to the AP distance (Pearson correlation infection protocol. The high sensitivities of aspirations and
coefficient 0.753, P<0.01) and the ML distance (Pearson correla- frozen cultures indicated their appropriateness in a diagnostic
tion coefficient 0.739, P<0.01) of the tibial plateau. This study work-up of suspected cases of deep joint infection. This has
showed that the common peroneal nerve is at risk of direct
lesion during the release of the postero-lateral capsule, not

478 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 479

immediate implications for our practice since initial clinical SCIENTIFIC EXHIBIT NO. SE22
screening combined with cultures and frozen sections will Failed TKA: The Survivorship of Polyethylene Tibial
continue to be part of our infection protocol.
Insert Exchange Only at the Time of Revision
SCIENTIFIC EXHIBIT NO. SE21 Jack M Bert, MD, Saint Paul, MN (e – Exactech)
Minimally Invasive Knee Arthroplasty: Early Kathleen Killeen, OT, Saint Paul, MN (n)
Complications and Difficulties Wenjun Ma, MS, Saint Paul, MN (n)
Susan Clay Mehle, BS, Saint Paul, MN (n)
Michael A Mont, MD, Baltimore, MD
Modular tibial polyethylene inserts (PI) were originally intended
(a, e – Stryker Orthopaedics)
for ease of revision surgery when polyethylene failure occurs in
Peter M Bonutti, MD, Effingham, IL total knee arthroplasty (TKA). However, recent articles have
(a, e – Stryker Orthopaedics) concluded that femoral and tibial component revision (FTCR)
David R Marker, BS, Baltimore, MD (n) in addition to PI exchange results in longer survivorship subse-
Johannes F Plate, BS, Heidelberg, Germany (n) quent to revision TKA. This study compares the survivorship of
German A Marulanda, MD, Baltimore, MD (n) 57 PI only revisions compared to 174 cases of FTCR in a
Thorsten M Seyler, MD, Baltimore, MD (n) community joint registry. Seven thousand five hundred thirty-
Minimally invasive surgery, including the technique of reduced one TKA’s were reviewed between 1991 and 2005. Two hundred
incision, quadriceps sparing techniques, in situ bone cuts, and thirty-one were revised and a second revision for removal,
non-everted patella has generated significant interest and exchange, and/or addition of a prosthetic component was the
controversy in the orthopedic community. As is often the case endpoint. Analysis was conducted using Kaplan-Meier survival
with new procedures, surgeons performing these minimally function, Log-Rank tests and Cox PH regression. Fifty-seven of
invasive surgeries have encountered new difficulties and unique the 231 revision cases (24.7%) were PI revisions, with five
challenges not previously found when using traditional tech- resulting in a second revision (8.8%). One hundred seventy-four
niques. This study examines the issues and complications specif- cases had FTCR and11 had a second revision (6.3%). The cumu-
ically related to performing minimally invasive techniques for lative revision rate from first to second revision was 21% (CI =
knee replacements. The authors have used a minimally invasive 8%, 34%). For PI revision only, the cumulative revision rate was
approach on all knees for the past six years. This study evaluated 13% (CI = 1%, 25%). For FTCR, the cumulative revision rate was
the first 1,500 consecutive cases of minimally invasive total knee 24% (CI = 7%, 41%) . The risk of second revision was not signif-
arthroplasty with up to 6 year follow-up. Patients were assessed icantly different for PI versus FTCR (HR=1.45, 95% CI = 0.50-
for overall complications including rate of manipulations, reop- 4.17, p-value=0.49). The risks of having a second revision did
erations, infections, and component revisions. In addition, a not differ significantly by gender or age category. In this study,
literature search using the databases of the National Library of patients in a community joint registry who had tibial polyeth-
Medicine and the National Institutes of Health was conducted to ylene exchange only at the time of revision TKA had similar
identify all articles published between January 1986 and March survivorship to those that had femoral and tibial component
revision.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

2006, which evaluated clinical outcomes in patients who under-
went minimally invasive knee surgery. No restriction on the
origin or the language of the publications was applied. Key SCIENTIFIC EXHIBIT NO. SE23
words utilized in the search were minimally invasive in combi- Patellar Cut Sagittal Tilt Is Predictive of Peri-pros-
nation with unicompartmental knee arthroplasty, total knee thetic Patella Fracture in Cemented TKA
arthroplasty, complications, and revision knee arthroplasty.
James Chow, MD, Chicago, IL (n)
Studies with less than ten patients were excluded. There were 57
patients with complications: 35 manipulations, 17 arthroscopic Wayne M Goldstein, MD, Morton Grove, IL
procedures for painful patello-femoral crepitus (dense lateral (a, c – DePuy, a, c – Smith & Nephew, c – Innomed)
band abrading against the lateral femoral condyle, removal of Alexander Gordon, MD, Highland Park, IL (n)
excess cement), 3 tibial component revisions, 1 patella revision, Gabriel Levi, MD, Chicago, IL (n)
1 full revision, and 3 infections. There were 2 other knees with Jennifer J Connor, MD, Chicago, IL (n)
impending radiographic failures. There were no other progres- James Baker, MD, Oak Park, IL (n)
sive radiolucencies. Overall, new surgical techniques must be Adam Schwartz, MD, Chicago, IL (n)
evaluated for any unique complications or difficulties. By care- Bettina Ann Chow, MA, Chicago, IL (n)
fully studying the drawbacks and issues of the techniques, the
Jill Branson, RN, Kildeer, IL (n)
surgeon is able to make improvements and identify any reme-
dial protocols which may be needed. From this study group, the Patellar cut geometry has been proposed to influence patellar
greatest concern for MIS TKA appears to be tibial component fracture in patellar resurfacing total knee arthroplasty (TKA). To
loosening and this may be related to decreased exposure and our knowledge, there are no large studies in current literature
possibly poor cement pressurization of the tibial component. directly examining the association of patella fractures to the
The length of the tibial keel combined with the large surface area integrity of the patellar cut. This paper examines the thickness
makes this area the greatest risk and the area which should be and obliquity of the bony patellar resection in 74 patella frac-
most closely monitored for long-term implant survivorship with tures occurring in cemented all-polyethylene patellar compo-
MIS TKA. nents. We retrospectively reviewed 5,073 TKAs performed
between 10/4/88 to 8/31/2004 by a single surgeon. Within this
period, 74 peri-prosthetic patella fractures in 68 patients were
identified and compared to a matched control group. Extensive
chart review was performed. Thickness and tilt of the remaining
patellar bone was measured using both merchant and lateral
radiographs. Geometric and statistical analysis was performed

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
479
PPSE 07:Layout 1 1/12/07 1:41 PM Page 480

on all reviewed data. Patellae with greater sagittal tilt were 1.196 SCIENTIFIC EXHIBIT NO. SE25
times more likely to experience a fracture than those with a more 12-Year Results of Cementless Total Knee
neutral cut angle (p less than .001). Fractured patellae had an
average of 8.79 degrees tilt in the sagittal plane prior to fracture. Arthroplasty
Non-fractured patellae had an average sagittal tilt of 5.03 Roberto Vigano, MD, Milano, Italy
degrees. No relationship was found with respect to presence of (a – Smith & Nephew, Inc.)
lateral release, body mass index, range of motion, age at surgery, Leo A Whiteside, MD, Saint Louis, MO
knee society score, thinness of residual bone stock, or size of (a, b, c – Smith & Nephew Inc.)
implant. Patella fracture after TKA is predicted by the geometry
This study evaluates the effectiveness of cementless total knee
of the residual patella after resurfacing at the time of surgery.
arthroplasty done consecutively in 1,320 patients (1,562 knees)
Specifically, greater tilt in the sagittal plane seems to affect this.
from October 1993 to October 2000. The Profix total knee
Improvement in surgical technique to retain a more level cut
system (cleared by the FDA for use as described by product
should theoretically help prevent this complication. Our exhibit
labeling) was used in all patients. Clinical results were entered
will demonstrate a proposed methodology for maintaining such
prospectively in a computerized database and were evaluated at
a level patellar resection.
5 and 10 years postoperatively. A group of 125 active, heavy
patients (less than 55 years, greater than 90kg) was segregated to
SCIENTIFIC EXHIBIT NO. SE24
compare the results with those of the standard older, less heavy
Avoiding Lateral Release in Primary TKA: The patients. The active, heavy patient group had a statistically signif-
Relationship Between the PCL and Patellofemoral icantly higher (p<0.05) rate of mild pain (21 percent) and inter-
mittent swelling (15 percent) compared with that of the
Tracking standard patient group (mild pain 10 percent, intermittent
Theodore Firestone, MD, Scottsdale, AZ (n) swelling 4 percent). The mean Knee Society scores were similar
Robert W Eberle, Apex, NC (n) between the groups at 5 years and 10 years postoperatively; the
Lateral retinacular release (LRR) increases the morbidity of total active, heavy patient group score was 92±4 at 5 years, and 93±3
knee arthroplasty (TKA). While intra-operative patellar tilt at 10 years postoperative, and the standard group score was 94±5
and/or subluxation occur commonly during the trialing stage of at 5 years, and 95±4 at 10 years postoperative. None of the knees
TKR, the lateral retinaculum is rarely the culprit. Preoperatively, in the active, heavy group loosened, but three patients in the
if the patella is centered without subluxation then, following standard group who had surgery in 1993 had femoral compo-
correct component implantation, the patella should track nent loosening because of a technical problem with instrumen-
without subluxation. The authors propose that excessive femoral tation. No additional incidence of clinical or radiographic
rollback due to PCL tightness often leads to intra-operative loosening has occurred since the instrumentation and implants
patellar subluxation. If the collateral ligaments are appropriately were corrected. One patient in the active, heavy group required
tensed the treatment of the femoral rollback is PCL release. This polyethylene component revision for wear. Each group had less
reduces the tibia while centering the patellar component. An than 1% unexplained severe pain, but this number did not
LRR should only be necessary in cases where patellar subluxa- increase with time. Cementless technique with this knee design
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

tion is noted radiographically on the preoperative sunrise view. has been highly effective at every age and activity level.
The purpose of this study was to examine the relationship
between the PCL and patellofemoral tracking at the time of CR- SCIENTIFIC EXHIBIT NO. SE26
TKA and propose an algorithm for avoiding lateral retinacular Analysis of Variation and Automated Measurement
release (LRR). We examined 100 consecutive primary TKAs with
radiographically well aligned patellofemoral articulations on the of Adult Femora Using Sex-Specific Atlases
preoperative sunrise view. Intra-operatively, using a trans-vastus Mohamed Mahfouz, PhD, Knoxville, TN (a – Zimmer)
approach, with the PCL retaining trial components in place, Robert E. Booth, Jr, MD, Philadelphia, PA (n)
patellar tracking was graded (1 - central tracking with no thumbs Jean-Noel A Argenson, MD, Marseille, France (n)
n = 23, 2 - central tracking with one suture n = 33, 3 - slide and Brandon Cole Merkl, BSc, Knoxville, TN (a – Zimmer)
tilt not corrected with thumb or suture n = 40, 4 - patellar Abdel Fatah Emam, BSc, Knoxville, TN (a – Zimmer)
subluxation n = 4). Excessive rollback was identified as the Michael J Kuhn, BSc, Knoxville, TN (a – Zimmer)
etiology of patellar mal-tracking in grades 3 and 4. In these cases,
Emily R Pritchard, BSc, Knoxville, TN (a – Zimmer)
a release of the PCL by controlled perforations was performed.
The release was deemed appropriate when the tibial insert Quantifying differences in femoral size and shape between
would reduce posteriorly and the patella would track centrally. males and females has extensive applications from forensics to
There were no LRRs performed in this series. However, there prosthesis design. By applying strong statistical techniques such
were 4 cases in which intra-operative conversions to a posterior- as Principal Component Analysis, certain three-dimensional
stabilized TKA were necessary. In the remaining cases, release of (3D) morphological variations of adult femora can be quanti-
the PCL utilizing controlled perforations resolved intra-operative fied over a wide range of expected femoral sizes. Using a statis-
grades 3 and 4 patellar tracking to grade 1 (no thumbs). There tical atlas for each sex, sex-specific comparisons can be made.
was no radiographic evidence of patellar tilt or subluxation in Each atlas is constructed from a set of canonical shape instances
those cases with intra-operative patellofemoral mal-tracking that have been created using a novel 3D-3D matching method
(grades 3 and 4). No postoperative manipulations were to regularize surface models of adult femora that have been
required. In conclusion, the majority of CR-TKA cases with manually segmented from 3D image data. Statistical atlases
patellar tilt or subluxation intra-operatively can be corrected allow for sex-specific comparisons between male and female
using a controlled release of the PCL thus avoiding LRR. femurs scaled to be the same length. Twenty-nine variables were
measured to be statistically significant shape differences
(p<0.05) exist between male and female femora. The atlas also
provides enough information to automatically calculate relevant

480 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 481

axes and angles such as the transepicondylar axis (TEA) and. By measuring pressure disbursement points. When a load is applied
using this methodology gender variation can be quantified in a to the mat, the most ink will be deposited at the locations of
manner relevant to orthopedic prosthesis design. An extensive highest pressure because all layers of the mat are compressed by
comparison of these surgical measurements for 106 males and the applied load. There were usually two distinct areas of high
92 females brings to light significant differences in their femoral stress. One was located over the tibial tuberosity and the other
anatomy. Without accounting for these differences in current over the middle of the anterior surface of the patella. The inten-
prosthesis design yields limited sizing accuracy for both males sity of stress most often varied over the tuberosity, where more
and females. body fat or rotation of the leg changed its location or intensity.
There is little written on kneeling after total knee replacement
SCIENTIFIC EXHIBIT NO. SE27 except that many patients do not feel comfortable attempting
Comparison of Highly Cross-Linked Polyethylene the maneuver or are worried it will cause injury. Danger to the
patella prosthesis during kneeling has not been studied. We have
with Standard Polyethylene in Total Knee cautioned patients of this yet since it is likely intermittent, we
Arthroplasty have tried to accommodate the desires of some patients. Based
Edward J Prince, MD, Saint George, UT (e – Zimmer) on these pressure patterns, we began to place the total knee
Aaron Adam Hofmann, MD, Salt Lake City, UT arthroplasty incision medial to these highest stress points. After
(e – Zimmer) 12 months time, there is little discomfort kneeling after using
this modified incision location.
Stuart C Marshall, MD, La Jolla, CA (e – Zimmer)
Justin Dazley, MD, Stony Brook, NY (e – Zimmer) SCIENTIFIC EXHIBIT NO. SE29
The purpose of this study is to compare the radiographic and
clinical outcomes of patients receiving a total knee arthroplasty
Evaluation of Complications in 600 Mini-Subvastus
using a highly cross-linked or standard polyethylene liner with a Total Knee Arthroplasty
minimum follow-up of five years. Highly cross-linked polyeth- William C Schroer, MD, Saint Louis, MO (a, e – Biomet)
ylene became available for use in February of 2001 and was used Paul Diesfeld, PA-C, Saint Louis, MO (a – Biomet)
consecutively at this institution since that date. We retrospec- Mary E Reedy, RN, Saint Louis, MO (a – Biomet)
tively reviewed the first 100 patients receiving this implant and
Angela LeMarr, RN, Saint Louis, MO (a – Biomet)
compared them to 100 patients immediately preceding this date,
Concerns exist that limited exposure and longer surgical time
who received a standard ultra-high molecular weight polyeth-
with minimally invasive (MIS) techniques may lead to increased
ylene liner. All patients underwent routine physical exams and
complications following total knee arthroplasty (TKA). This
radiographs from which a knee score was calculated. Of the 200
study evaluates the complication rate and need for further
patients, 10 had died and 20 were lost to follow-up, leaving 82
surgery in our first 600 mini-subvastus TKA patients. All proce-
patients in the standard group and 88 patients in the highly
dures were performed by a single surgeon with a PS cemented
cross-linked group with an average follow-up of 66 months and
TKA. Since March 2003, this MIS procedure has been utilized in
55 months respectively. Six patients in the standard group were
99% of our primary TKA. Data was collected prospectively. Knee

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

revised: two for infection, two for aseptic loosening and two for
specific complications that required further knee surgery, more
instability. Two patients in the cross-linked group were revised
frequent office visits for wound management, or administration
for instability. Knee scores for each group were the same at 197.
of oral antibiotics were determined. Forty patients required addi-
Six patients in the standard group had radiographs with grade I
tional office visits for increased surveillance of surgical wounds.
osteolytic lesions. In this study, highly cross-linked polyethylene
None of these patients required surgery for wound or hematoma
showed similar clinical findings to standard polyethylene,
concerns. Two knees developed deep infections that required
however, there were fewer revisions and no osteolytic lesions
two-stage revision. Three knees have been revised due to tibial
seen on radiographs. The six osteolytic lesions in the standard
component failure. Six patients underwent further knee surgery
polyethylene group is concerning at this length of follow-up and
for other knee complications during their first year of follow-up
may suggest polyethylene wear debris.
that did not require knee revision. Seventeen patients were diag-
SCIENTIFIC EXHIBIT NO. SE28 nosed with a patella clunk syndrome that required arthroscopic
debridement. Four knees underwent successful closed manipu-
Evaluating Stress Over the Anterior Knee with New lation at six weeks postop. Five patients (0.8%) required revision
Kneelprint Concept during the two years of follow-up: two for infection and three for
Jill Branson, RN, Kildeer, IL (n) tibial component failure. The incidence of patella clunk
Wayne M Goldstein, MD, Morton Grove, IL (a – DePuy, syndrome was consistent with reports in the literature and was
eliminated with a newly designed femoral component.
Smith & Nephew, c – DePuy, Smith & Nephew, Innomed)
Excluding the patella clunk patients, 1.8% of our MIS TKA
Alexander Gordon, MD, Highland Park, IL (n) required surgery during the first two years of follow-up. Overall,
Christopher Simmons, BS, Morton Grove, IL (n) the use of the mini-subvastus surgical technique did not increase
Kimberly A Berland, CST, Warrenville, IL (n) the incidence of complications or develop new modes of TKA
Many patients inquire if they are able to kneel after a total knee failure. The rate of both major and minor knee complications
replacement. It is part of daily life in certain cultures. While the decreased as surgical volume increased.
high flex design will allow patients to get low to the ground, the
act of cleaning a bathtub, gardening, or kneel in prayer require
bending down on both knees. A sample of 25 healthy volunteers
and 10 total knee patients (two years post op) were asked to
kneel down on a Harris foot force imprinter with simultaneous
pressure applied to both knees. This imprinter produces a weight
bearing image of the anterior knee (similar to the foot), thereby

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
481
PPSE 07:Layout 1 1/12/07 1:41 PM Page 482

SCIENTIFIC EXHIBIT NO. SE30 correlation between these measurements was determined. The
Implant Sizing in the Female Total Knee difference and degree of variation between the measurements
achieved using standard radiograph and navigation data was
Arthroplasty evaluated. In addition, the ideal alignment was compared to the
Alexander Gordon, MD, Highland Park, IL (n) accepted intra-operative alignment as measured by the naviga-
Wayne M Goldstein, MD, Morton Grove, IL (a – DePuy, tion system. Radiograph and navigation alignment data exhib-
Smith & Nephew, c – DePuy, Smith & Nephew, Innomed) ited a very weak correlation. Radiographic results exhibited a
Jill Branson, RN, Kildeer, IL (n) greater range and variability than the navigation data in each of
Christopher Simmons, BS, Morton Grove, IL (n) the three measurement criteria. Radiographic measurements had
a tendency to overestimate the degree of varus in the anterior-
Kimberly A Berland, CST, Warrenville, IL (n)
posterior mechanical axis, the degree of femoral flexion, and
The authors studied the need for a female femoral component degree of posterior tibial slope, as compared to intra-operative
design, based on analysis of 877 TKAs of a single implant design. navigation measurement results. The absence of a strong corre-
We compared femoral templates from five manufacturers and lation between radiograph and navigation alignment measure-
evaluated medial to lateral measurements for each equivalent AP ments and the degree of inter-observer measurement correlation
dimension. We compared Sigma RP (DePuy) to one manufac- suggests that standard radiographs may not have the inherent
turer promoting female sizing and contrasted results to accuracy needed to function as the primary alignment evalua-
caucasian anthropometric data. We studied gender related to tion tool in TKA performance. The results of this study can ulti-
femoral and tibial sizing in the Sigma RP TKAs performed over mately be used to gauge the degree of confidence one should
a two year period during 2004 (360) and 2005 (517), and revi- place on standard radiographs as the primary measure of align-
sions due to over-sizing and assessed if there was size variation ment performance in computer-assisted TKA.
between knees in bilateral TKA. For the four most common AP
sizes fitting the female patient, we found medial lateral meas- SCIENTIFIC EXHIBIT NO. SE32
urements for the Zimmer Next Gen femur averaged 5.7mm
wider than the Sigma RP. Triathalon averaged 1.5mm wider. In
3D Morphological Data From Biplanar X-Ray
the author’s cohort, the average of both the femoral and tibial Images for TKA Using Sex-Specific Atlases
components for a female patient was a size 4 (A/P was 65.6mm). Abdel Fatah Emam, BSc, Knoxville, TN (a – Zimmer)
Female knees more frequently had a tibial component one size Mohamed Mahfouz, PhD, Knoxville, TN (a – Zimmer)
down from the femoral component and male patients had the Robert E. Booth, Jr, MD, Philadelphia, PA (n)
same size component. The medial to lateral dimension of the
Jean-Noel A Argenson, MD, Marseille, France (n)
Sigma RP was smaller than many total knee replacements avail-
able as dramatized when juxtaposing templates next to the Brandon Cole Merkl, BSc, Knoxville, TN (a – Zimmer)
commercially available femur with the widest medial to lateral Michael J Kuhn, BSc, Knoxville, TN (a – Zimmer)
dimension. This templating study indicates there are manufac- The clinical outcome of a total knee arthroplasty (TKA) is mainly
turers that might be at the extremes on the large medial to lateral determined by the accuracy of the surgical procedure itself.
dimension for a given AP dimension in the femoral component. Using patient-specific computer models of the patient’s knee
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

In those cases, there may potentially be evidence of soft tissue bones the surgeon can plan the optimal strategy. Then, during
pain; particularly in women. The medial to lateral dimension of surgery, a navigation system can guide the surgeon in completing
the patellofemoral articulation may be narrow in a female, yet the planned strategy. The method is based on creating three
impingement in this area is doubtful from a clinical perspective. dimensional (3D) models of the patient’s anatomy from two
dimensional (2D) x-ray fluoroscopy images. For the morpho-
SCIENTIFIC EXHIBIT NO. SE31 logic acquisitions, we use a method based on the registration of
Lack of Correlation Between Radiographic and two biplanar 2D x-ray fluoroscopy images with a 3D statistical
deformable model defined for each sex from which the pose and
Intra-operative Navigation Measurement of Limb the shape of the bone is determined. In order to verify the ability
Implants of our bone morphing techniques to extract anatomical features
Mark A Yaffe, BS, Chicago, IL (n) from the two biplanar X-ray images, we performed comparisons
S David Stulberg, MD, Chicago, IL (e – Aesculap) with 15 computed tomography CT data sets. The experiments
have demonstrated that our model building method accurately
Samuel Koo, MD, Chicago, IL (n)
and compactly captures the shape of the full femur and proximal
In order to evaluate the accuracy of computer-assisted TKA, tibia with an average deviation of only 0.28mm, a deviation of
precise postoperative measurements of limb alignment are less than a voxel in most 3D medical images. Bone Morphing
essential. The purpose of this study is to determine the strength using biplanar X-ray images provides an accurate, fast, and user-
of the association between measurements taken from standard friendly method that can provide morphologic as well as
postoperative radiographs and intra-operative navigation meas- geometric data. This system has the advantage of saving time
urements, as well as the degree of consistency by which these during surgery in addition to accuracy over the optical 3D local-
measurements are made. Additionally, an appreciation of the izer systems. Therefore, this method should be considered as an
difference that exists between ideal alignment and clinically alternative to the CT-based method and 3D localizer systems.
acceptable alignment as assessed through intra-operative naviga-
tion can demonstrate the subtle limitations of a navigation
system. Fifty-one computer-assisted TKA were performed. For
each TKA, mechanical axis, femoral, and tibial implant align-
ment measurements were recorded, both intra-operative using
the navigation system and with anterior-posterior and lateral
view radiographs taken at one-month postoperative. Each radi-
ograph was evaluated by two independent observers and the

482 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 483

SCIENTIFIC EXHIBIT NO. SE33 errors is presented. Case examples of typical varus/valgus defor-
Treatment of Septic Joints with a Single-Stage mity demonstrate the baseline surgical technique strategy for
bone cuts and ligament handling. Modifications to the baseline
Arthroplasty and Intra-articular Antibiotics strategy are presented for treatment of extreme varus/valgus
Tariq Nayfeh, MD, Ellicott City, MD malalignment which occur during cases of femoral condylar
(d – Smith & Nephew, Inc.) necrosis, condylar hypoplasia, trauma, extreme wear, flexion
Leo A Whiteside, MD, Saint Louis, MO (a, b, c – Smith & contracture, etc. Intra-operative bone cut and ligament balancing
Nephew, Inc., e – Whiteside Biomechanics, Inc.) simulations will aid participants’ understanding of corrective
surgical technique strategy by demonstrating the potential posi-
Infected total joint arthroplasty was treated with direct infusion
tive or negative consequences of a given bone resection. This
of antibiotics and primary reconstruction using porous-coated
decision-making tool provides surgeons an easy and accurate
implants without cement or bone graft. This method was
feedback mechanism, creating a traceable pathway for error
compared retrospectively to a similar group of infected total
analysis. Contemporary instrumentation and navigation may be
joints treated with a two-stage procedure and identical antibi-
useful for planning and executing bone cuts, implant alignment
otic infusion technique. In the single-stage group (31 knees) the
and ligament balancing. However, prospective and real-time
components were removed, the joint debrided, and new
analysis of these decisions helps avoid costly mistakes that can
components implanted without cement or bone graft. Two
lead to less optimal results.
indwelling Hickman catheters were placed and the patient
received organism-specific intra-articular antibiotics for 6
SCIENTIFIC EXHIBIT NO. SE35
weeks. In the two-stage group (22 knees), debridement and
spacer were followed by 6 weeks intra-articular antibiotics Posterior Stabilized Constrained Total Knee
through Hickman catheters, then revision arthroplasty was Arthroplasty for Complex Primary Cases
done using porous-coated implants. Wound complication was Keith R Berend, MD, New Albany, OH
significantly (p<0.02) more common in the two-stage group
(a, d, e – Biomet, Inc.)
(6) than in the one-stage group (1). Cardiovascular complica-
tions were significantly (p<0.05) more common in the two- Adolph V Lombardi, Jr, MD, New Albany, OH
stage group (10) than in the one-stage group (2). Knee score at (a, c, d, e – Biomet, Inc.)
2 years was significantly (p<0.04) better in the one-stage group Joseph Leith, MD, Hilliard, OH (n)
(89±5) than in the two-stage group (74±6). Each group had two Gerardo Mangino, MD, Cuajimalpa, Mexico
failures for reinfection. Three of four were treated successfully (a – Biomet, Inc.)
with rerevision and treatment with intra-articular antibiotics. Joanne B Adams, New Albany, OH (a – Biomet, Inc.)
One had amputation for chronic osteomyelitis. Intra-articular Infrequently degenerative joint disease will present with
antibiotics and noncemented revision arthroplasty effectively complex bony and ligamentous deformities. A modular poste-
treated chronically-infected TKA. Single-stage revision total rior stabilized constrained (PSC) total knee may accomplish
knee arthroplasty was as effective in eradicating infection as pain relief, improve function, and provide longevity. This study
two-stage arthroplasty using this technique. The single-stage

PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

reviews the experience with a single PSC design used in complex
procedure had more wound and cardiovascular complications. primary TKA. Fifty-eight primary TKA were performed using a
These findings support using single-stage revision in cases PSC design for cases of complex ligamentous and bony defor-
treated with cementless revision and intra-articular antibiotics. mity and deficiency. Average age was 64 years, height 64 pounds,
and weight 168 pounds. Preop flexion averaged 89 degrees.
SCIENTIFIC EXHIBIT NO. SE34 Preop Knee Society pain scores averaged 12. Follow-up averaged
Intraoperative Assessment of Bone Cuts and 54 months. Knee society pain scores improved to 44 and range
Ligaments to Guide Surgical Technique During TKA of motion improved to 101 degrees. Eight knees (13.8%)
required manipulation for stiffness and arthrofibrosis.
W Andrew Hodge, MD, West Palm Beach, FL
Subsequent infection required two-stage treatment in 2 knees
(c, e – Encore Medical) (3.4%). Four knees were revised for aseptic causes (6.9%): 2
Sabine Schmitt, MD, Mannheim, Germany (n) extensor mechanism complications, 1 for instability, and 1
Melinda K Harman, MS, Palm Beach, FL periprosthetic fracture. No knees were revised for aseptic loos-
(a, e – Encore Medical, a – OrthoSoft) ening. In the unusual primary TKA scenario a PSC design is
Kim Mitchell, BS, West Palm Beach, FL (n) required to address bony and ligamentous deformities and defi-
Scott A Banks, PhD, Gainesville, FL (c, e – Encore Medical) ciencies, but the results are inferior to more simple primary TKA
Replacement of arthritic bone and cartilage loss with similar with a higher rate of infection and arthrofibrosis. However, the
thickness prostheses, while also balancing ligaments, is the longevity of implant fixation and stability are excellent with no
premise of measured bone resection during total knee arthro- cases of aseptic loosening. When increased constraint and fixa-
plasty (TKA). The magnitude of bone resection impacts align- tion are required, a PSC design is a viable option for the treat-
ment and soft tissue balancing, and greatly influences TKA ment of these complex scenarios.
stability and longevity. However, up to 20% error in the total
removed bone thickness can occur using standard TKA instru-
mentation. Making appropriate adjustments intra-operatively is
difficult without a surgical technique strategy to quantifying
these errors. This multicenter exhibit uses radiographs, and intra-
operative bone measurements and ligament assessments, to
characterize varus/valgus deformities that exist in TKA. A simple
quantitative decision-making tool to guide surgical technique
and to aid recognition and correction of potential bone cut

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
483
PPSE 07:Layout 1 1/12/07 1:41 PM Page 484

SCIENTIFIC EXHIBIT NO. SE36

Rotatory Anteromedializing Tibial Tubercule
Osteotomy: A New Technique
Carlos Prada, MD, Medellin, Colombia (n)
Taking up the studies of patellar biomechanics and its vectorial
resultant force, an osteotomy that joins all the effects of the ante-
riorization, medialization, and rotation of the tibial tuberosity
was designed, in order to change the patella’s support points as
a treatment for pain and malalignment, by changing the patella’s
contact over the patellofemoral canal. By the scope, the release
of the distal 2/3 of the patella lateral retinaculum is done, and
by a small 4cm. transverse incision at the tibial tubercule level,
an oblique triangular shape osteotomy with three bone cuts is
moved medialy, anteriorly, and with a rotation component in
the coronal plane and fixed with two cancellous screws over the
medial ridge left with the medial cut of the osteotomy. A 20mm
medial advancement with 13mm. of ateriorization and 30º of
medial rotation is achieved. By adding up the osteotomy’s excel-
lent (59.9%) and good (32.4%) results, we have a 91.9% of satis-
faction and acceptance of the procedure. Only 8.1% reported
relative recuperation with recurring pain, and these corre-
sponded to the cases with chondromalacia of grades III and IV.
Not one person reported being in worse conditions than the
ones they were in before the surgery, on the contrary, their pain
diminished Although patellofemoral pain can be originated by
several factors, among them malalignment, Excessive Lateral
Patellar Pressure, trauma, etc, distal realignment osteotomies
lessen the symptoms of pain, probably because of the change in
the contact points of the patella over the patellofemoral groove
when a healthy condral tissue, or one in better conditions than
the one exposed to the excessive pressures of a patella that is not
doing a balanced flexion/extension movement is used.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE

484 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 485

BASIC RESEARCH
SCIENTIFIC EXHIBITS assumption was evaluated by comparing postoperative clinical
ROM after 28mm THA or SRA. In order to optimize ROM after
SRA, the influence of different SRA femoral component posi-
tions on ROM was also analyzed with a computer model.
SCIENTIFIC EXHIBIT NO. SE37 Restoration of normal ROM is important after hip arthroplasty.
◆Effects of Electrical Physical Stimuli on Articular With the greater head-neck diameter ratio of THA, better ROM
Cartilage should be achieved compared to hip resurfacing (SRA). This
assumption was evaluated by comparing postoperative clinical
Stefania Setti, PhD, Carpi, Italy (e – Igea) ROM after 28mm THA or SRA. In order to optimize ROM after
Leo Massari, MD, Ferrara, Italy SRA, the influence of different SRA femoral component posi-
(a – Regione Emilia Romagna) tions on ROM was analyzed with a computer model. Patients
Francesco Benazzo, MD, Pavia, PV Italy (n) were randomized for THA (28mm head) or SRA. Hip ROM was
M DeMattei, MD, Carpi, Italy measured by a blinded observer pre and post operatively using
(a – Regione Emilia Romagna) computer software and digitized photographs where osseous
Fini M, MD, Carpi, Italy (a – Regione Emilia Romagna) landmarks were identified. The influence of translation and
Physical stimuli, mechanical and electrical, modulate cartilage orientation of the SRA component on ROM was also evaluated
metabolism. We focus on Pulsed ElectroMagnetic Fields (PEMFs, with an animated 3-D model. Pre operative ROM of 83 SRA and
I-ONE, Igea, Italy) as they allow to treat homogenously the 79 THA was similar. No difference was found between THA and
whole cartilage surface and thickness and the underling SRA for total ROM arc (204.9°versus 218.1°), rotation (47.7°
subchondral bone. In vitro, PEMFs increase the binding between versus 44.3°), flexion-extension (118.1° versus 120.1°), and
adenosine and A2A adenosine receptor. It has been shown that abduction-adduction (43.1° versus 42.9°), (p>0.05). The
drugs with A2A adenosine receptor agonist activity prevent artic- computer model showed 23° increased in total ROM with larger
ular cartilage degeneration in animals. We hypothesized that the SRA component, little influence of ante/retroversion or
adenosine agonist effect of PEMFs can also prevent cartilage varus/valgus position and improved flexion of 35° with anterior
degeneration. Here we discuss our preclinical work. . Full thick- translation up to 4mm. The head-neck diameter ratio of THA is
ness explants obtained from bovine articular cartilage were 2.0 and varies from 1.3 to 2.0 in SRA. In clinical settings, other
exposed to PEMFs of different frequencies and amplitudes. The factors should therefore account for the lack of difference in
most effective parameters in stimulating proteoglycan synthesis ROM such as: fear of dislocation in THA limiting full rehabilita-
were subsequently used in in vivo experiments. The effect of tion, reduced succion effect of smaller head or preservation of
stiff capsular tissue after THA. ROM after SRA can be optimized

PAPERS, POSTERS & SCIENTIFIC EXHIBITS BASIC RESEARCH

PEMFs on Dunkin Hartley knee osteoarthritis was investigated
by Mankin score and by histomorphometric and densitometric by restoring normal femoral head-neck offset with larger
analysis. Osteochondral grafts were performed in the knees of components or with anterior translation.
sheep. The effect of PEMFs was evaluated by histologic and
histomorphometric analysis after 1 and 6 months. In explants,
SCIENTIFIC EXHIBIT NO. SE39
1.5mT, 37Hz PEMFs induced the largest increase in proteoglycan Future Clinical and Economic Impact of Revision
synthesis (p<0.05). In Dunkin Hartley, PEMFs treatment THA and TKA
(6hours/day, 3months) prevented cartilage degeneration
Steven M Kurtz, PhD, Philadelphia, PA (n)
(p<0.0005) and subchondral bone sclerosis (DXA, p<0.01).
PEMFs favoured osteochondral grafts integration at 1month and
Kevin Ong, PhD, Philadelphia, PA (n)
prevented cyst formation (p<0.005). Fibrous cartilage was more Jordana K Schmier, MA, Alexandria, VA (n)
evident in control animals: 32% versus 15% PEMFs at 6 months. Fionna Mowat, PhD, Menlo Park, CA (n)
PEMFs are able to maintain cartilage health and to favour the Khaled J Saleh, MD, Charlottesville, VA (n)
healing of osteochondral grafts. These results provided the Henrik Malchau, MD, Boston, MA (n)
rational basis to design the clinical study CRES: Cartilage Repair Edmund Lau, MS, Philadelphia, PA (n)
and Electrical Stimulation. The projected revision burden of THA and TKA has been
reported previously, but potential economic consequences are
SCIENTIFIC EXHIBIT NO. SE38 still unknown. Retrospective studies have shown increasing
◆Range of Motion After Hip Resurfacing and THA: disparity between Medicare reimbursement and hospital
Clinical and Computer Model Analysis charges. This study quantifies the projected economic burden of
revision THA and TKA for Medicare enrollees, accounting for the
Martin Lavigne, MD, Montreal, Canada (a, e – Zimmer) projected adoption of these procedures, changes in procedural
Pascal-Andre Vendittoli, MD, Montreal, Canada charges and in the patient population. Medicare (1997 to 2004)
(a, e – Zimmer) and U.S. Census data were incorporated into a Poisson regres-
Sophie Mottard, MD, Saint Lambert, Canada (n) sion model to determine the projected economic impact of revi-
Dominique Plamondon, MSc, Montreal, Canada (n) sion THA and TKA through 2015 for hospital and surgeon
Renaud Winzenrieth, PhD, Montreal, Canada (n) charges and reimbursements, accounting for inflation. Annual
Natalia Nuno, PhD, Montreal, Canada (n) hospital charges for primary THA and TKA were estimated to
Restoration of normal ROM is important after hip arthroplasty. increase by 3.5X to $17.7 billion and by 4.6X to $41.7 billion,
With the greater head-neck diameter ratio of THA, better ROM respectively, between 2005 and 2015. Corresponding THA and
should be achieved compared to hip resurfacing (SRA). This TKA surgical charges were projected to increase by 1.9X to $1.9

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
485
PPSE 07:Layout 1 1/12/07 1:41 PM Page 486

billion and by 2.6X to $5.1 billion, respectively. Hospital charges SCIENTIFIC EXHIBIT NO. SE41
for revision THA and TKA were projected to be $7.1 billion and A Novel Osteolysis Model with Intramedullary
$4.2 billion; corresponding surgical charges were estimated as
$0.6 billion and $0.3 billion. Historical data showed reimburse- Infusion of Polyethylene Particles in a Cemented
ments were 32% to 38% of the charges per procedure. Despite Implant
the greater number of projected revision TKA procedures, revi- Kang Jung Kim, MD, Tokyo, Japan (a – Sankyo)
sion THA poses a more severe projected economic impact to Miho Iwase, Tokyo, Japan (a – Sankyo)
Medicare due the greater charges for each revision THA
Kouji Suda, PhD, Tokyo, Japan (a – Sankyo)
compared to TKA. This study establishes a novel statistical
framework for combining projections of the number and Kumakura Seiichirou, PhD, Tokyo, Japan (a – Sankyo)
charges of future surgeries. This information will be useful for Introduction: We reported osteolysis model with continuous
policy makers (CMS), hospital administrators, and surgeons infusion of polyethylene particles from an osmotic pump into a
serving the Medicare population. rat knee joint. However, radiographic osteolysis as seen in
human cases rarely took place due to low amounts of particle
SCIENTIFIC EXHIBIT NO. SE40 penetration at the bone-implant interface. We report a novel rat
model with intramedullary continuous infusion of particles
Agreement in Orthopaedic Radiographic Studies: around a cemented implant, in which massive osteolysis was
Is Kappa the Appropriate Statistic? established in two weeks postoperatively. Materials and
Thomas A Gruen, MS, Wesley Chapel, FL (e – DePuy) Methods: Ten wistar rats were randomized to osteolysis group
Jeffrey A Murphy, MS, Warsaw, IN (e – DePuy) and sham group (n=5, respectively). In osteolysis group, a
Despite the kappa statistic’s popularity in orthopaedic studies to cement-coated silicon tube (1.5cm in length and 0.5cm in diam-
assess agreement, the statistic changes dramatically based on the eter) with 5 holes (average diameter, 500 microns) was press-
prevalence of positive and negative readings. Knowledge of fitted into rat tibia, then silicon tube was led to be connected
kappa’s sensitivity to prevalence and awareness of more appro- with an osmotic pump containing polyethylene particles placed
priate statistics is lacking in the orthopaedic discipline. Serial X- in the back of a rat. In sham group, tibia was reamed by a rasp
rays from 48 primary total knee replacement patients were with the same size of the cement implant without particles. We
reread 1 month after initial reading by a blinded, independent evaluated peri-implant osteolysis radiographically and histo-
reviewer. Each patient had A-P, lateral, and merchant views at the morphologically two weeks after operation. Results: Massive
following postoperative time points: immediate, intermediate osteolysis was seen radiographically in all cases of osteolysis
(typically 3 to 4 years), and 5 years or greater. Presence or group while it was seen in no cases of sham group (p<0.01). The
absence of osteolysis was the primary outcome. Four agreement number of osteoclasts as well as inflammatory grades of the
statistics were calculated and compared to assess intra-observer interface membrane was significantly higher in the osteolysis
agreement: proportion agreement, kappa, PABAK, and Gwet’s group compared to the sham group (p<0.01). Conclusion: A
AC-1. The intra-observer evaluation of osteolysis in any view at novel rat model demonstrates that clinically relevant osteolysis
PAPERS, POSTERS & SCIENTIFIC EXHIBITS BASIC RESEARCH

any time period resulted in a proportion agreement = 0.79, is induced in two weeks via intramedullary continuous infusion
kappa = 0.57, PABAK=0.58, and AC-1 = 0.60. The prevalence was of polyethylene particles into bone-implant interface.
21%. When the prevalence increased to 94% in the Merchant
view, the proportion agreement was higher (0.94), however the
kappa was much lower (-0.03) with a corresponding PABAK of
0.88 and AC-1 of 0.88. Kappa is one of the most common statis-
tics used to assess radiographic agreement in orthopaedic
studies. However, the high prevalence in the merchant view
region of interest in this study resulted in a kappa statistic that
was inconsistent with the three other agreement statistics. As
opposed to reporting the popular kappa statistic, we recom-
mend also reporting proportion agreement, and either PABAK or
Gwet’s AC-1 statistic, when reporting intra-observer radiographic
agreement.

486 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 487

B OS (BOA RD OF ORTHOPAEDIC SPECIALTIES)

SCIENTIFIC EXHIBITS SCIENTIFIC EXHIBIT NO. SE77
Test Your Bone Tumor IQ
Musculoskeletal Tumor Society
SCIENTIFIC EXHIBIT NO. SE76 Carol D Morris, MD, New York, NY (n)
Anterior Cruciate Ligament Reconstruction Using Janet Sybil Biermann, MD, Ann Arbor, MI (n)
Navigation: A Comparative Study on 60 Patients Robert H Quinn, MD, Albuquerque, NM (n)
American Orthopaedic Society for Sports Medicine Michael P Mott, MD, Warren, MI (n)
Stephane Plaweski, MD, Grenoble, France (n) Kristy L Weber, MD, Baltimore, MD (n)
This Scientific Exhibit will provide an opportunity for partici-
Philipp Rosell, Grenoble, France (n)
pants to diagnose and manage common bone tumors in an
JuPiam Cazal, Grenoble, France (n)
interactive unknown format. Short clinical histories and perti-
Philippe Merloz, MD, Grenoble, France (n) nent studies on viewboxes will be presented as to most closely
Remi Julliard, MD, Grenoble, France (n) simulate the office experience. The most common tumors and
Background: Poor outcome in anterior cruciate ligament recon- clinical scenarios likely to be encountered by the practicing
struction is often related to tunnel position. Hypothesis: orthopaedist will be emphasized. Answers with an accompa-
Improving accuracy of the tunnel position will lead to improved nying discussion describing the appropriate treatment will be
outcome. Study Design: Randomized controlled trial; Level of proviced via a lift the flap mechanism following each vignette. In
evidence,1. Sixty patients were randomized to either standard addition a handout containing basic information for each of the
instrumentation or computer-assisted guides to position the featured tumors as well as references for additional reading will
tibial and femoral tunnels. The results were evaluated on clinical be made available.
outcome based on International Knee Documentation
Committee form (laxity) and radiologic assessment: radiologic SCIENTIFIC EXHIBIT NO. SE78
Lachman (Telos at 150 and 200 N) and analysis of the tunne Current Hot Topics in Orthopaedic Research
positions. International Knee Documentation Committee laxity
was level A in 22 knees in the conventional group (mean:
Orthopaedic Research Society
1.5mm at 100N) compared with 26 navigated knees (mean Anthony M DiGioia III, MD, Pittsburgh, PA (n)
Laxity: 1.3mm; P-.49). Laxity was less than 2mm in 96.7% of the Thomas D Brown, PhD, Iowa City, IA (n)
navigated group and 83% of the conventional group (P=.292). Christopher H Evans, PhD, Boston, MA (n)
Johnny Huard, PhD, Pittsburgh, PA (n)

PAPERS, POSTERS & SCIENTIFIC EXHIBITS BASIC RESEARCH

The variability of laxity in the navigated group was significantly
less than in the conventional group, with the standard deviation Tony Keaveny, PhD, Berkeley, CA (n)
of the navigated group being smaller than that in the conven- Jay R Lieberman, MD, Farmington, CT (n)
tional group (P=.0003 at 150N and .0005 at 200N Telos). A Maurizio Pacifici, PhD, Philadelphia, PA (n)
significant difference (P=.03) was found between the groups in
Scott Alan Rodeo, MD, New York, NY (n)
the ATB value (distance between the projection of the
Blumensaat line on the tibial plateau and the anterior edge of
Thomas A Wright, MD, Toronto, ON Canada (n)
the tibial tunnel), characterizing the sagittal position of the tibial Orthopaedic research continues to progress rapidly as new
tunnel (negative ATB values imply graft impingement in exten- methodology becomes available. Members of the Orthopaedic
sion). In the conventional group, mean ATB was -0.2 (-5 to +4), Research Society conduct investigations on a wide range of
whereas it was 0.4 (0 to 3) in the navigated patients. There were topics relevant to improving our knowledge of the etiology, diag-
no negative ATB values in the navigated group. This study nosis, and treatment of musculoskeletal disease. Many different
confirms that the accuracy and consistency of tibial tunnel posi- areas of expertise contribute to current orthopaedic research,
tion can be improved by the use of computer-assisted navigation including biochemistry, molecular biology, biomaterials, biome-
and that the clinical result in terms of laxity is more reliable. chanics, and advanced imaging. Some of the current exciting
areas of investigation include tissue engineering using stem cells,
adipose-derived cells, and muscle cells; studies examining the
effects of mechanical forces (stress and strain) on cells and
tissues; newly-identified mediators of bone resorption (osteo-
protegering) and bone formation (PTH) that may play impor-
tant roles in osteolysis and osteoporosis;gene expression in
healing bone, ligament, and tendon; novel imaging techniques
such as Fourier-transform infrared (FTIR) and double-quantum-
filtered NMR; new biomaterials that may be used for implants
and tissue regeneration, and gene therapy methods to induce
expression of key molecules in healing bone, cartilate, ligament,
tendon, meniscus, nerve, and muscle. Investigations in these and
many other areas by the Orthopaedic Research Society will lead
to advances in our understanding and treatment of muscu-
loskeletal diseases.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
487
PPSE 07:Layout 1 1/12/07 1:41 PM Page 488

FOOT AND ANKLE

PAPERS tarflexion was within 5 degrees of neutral in all cases, and rota-
tional alignment was equivalent to the contralateral extremity in
all cases. Regression analysis shows no relationship between
excessive varus or valgus alignment and decreased AOFAS scores
PAPER NO. 061 (p=0.39) All patients had improved pain and function scores
Outcome After Two Screw Fixation Technique of with mean improvements in AOFAS scores from 57.6 of 100
Ankle Arthrodesis points to 80.6 postoperatively. The modified Mann ankle
arthrodesis, performed with 2 retrograde screws, is a reliable and
Andrew Ariel Brief, MD, River Vale, NJ (n)
reproducible technique with a 95% union rate in patients with
John G Kennedy, MD, New York, NY (n) degenerative arthrosis of the ankle.
Walther Hartmuth Bohne, MD, New York, NY (n)
Monika Volesky, MD, Outremont, Canada (n) PAPER NO. 062
Abstract: Tibio-talar arthrodesis continues to be the gold-stan- Tibiotalar Arthrodesis Using a Custom Blade Plate
dard procedure in the treatment of end-stage ankle
Glenn Wera, MD, Cleveland, OH (n)
arthrosis.Over 30 different methods of obtaining ankle fusion
have been described. Analysis of outcomes is widely variable, John K Sontich, MD, Cleveland, OH (n)
with many studies reporting on groups of mixed pathology and Brendan M. Patterson, MD, Cleveland Heights, OH (n)
fixation techniques, as well as groups with variable use of bone- Abstract: Ankle arthrodesis techniques vary but the use of blade
graft substitutes. The purpose of the present study was to report plates for ankle fusions is limited to a few studies. Furthermore,
on the outcomes of patients with endstage post-traumatic ankle the use of blade plate fusion for tibiotalar arthritis is limited to
arthrosis, who have undergone a single technique of tibio-talar one study with excellent results . Blade plates have been validated
arthrodesis by one surgeon over 14 years. The hypothesis of this in tibiocalcaneal arthrodesis . However, no one has revisited
study is that with meticulous bone surface preparation and the using blade plates exclusively for tibiotalar arthrodesis to our
use of a standard technique of 2 parallel retrograde screws, knowledge. Unlike other reports, our technique of tibiotalar
acceptable levels of ankle fusion can be achieved without the use arthrodesis utilizes a lateral approach and partial fibulectomy to
of bone graft substitutes in patients with end-stage degenerative allow for blade plate fixation. This approach allows sparing of the
arthritis. Study design: Retrospective cohort clinical study. After anterior and medial skin which is frequently compromised by
IRB approval, a record review revealed that 44 tibio-talar fusions trauma and prior surgery in the post traumatic arthritis patient.
were performed on 43 patients with isolated post-traumatic This investigation is a retrospective review of clinical and radi-
degenerative ankle arthrosis by the senior author between 1987 ographic outcomes in 20 patients who underwent tibiotalar
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

to 2000. 3 patients were excluded: 2 were lost to follow-up, and arthrodesis using a custom blade plate. An institutional review
1 patient died of unrelated causes. Exclusion criteria: rheuma- board approval of the study was obtained where the investigation
toid or inflammatory disease of the ankle tumors avascular was performed. Follow-up data was obtained via telephone inter-
necrosis talus idiopathic causes of ankle arthitis co-existing view, routine clinic appointments, and review of patient charts
subtalar or talonavicular arthrosis Indication for ankle fusion in and radiographs. The American Orthopedic Foot and Ankle
all patients was severe ankle pain, limiting ambulation and Society (AOFAS) Ankle Hindfoot Score was used to quantify
activities of daily living, and failure of conservative treatment. lower extremity performance at the time of last follow up.
End-stage ankle arthrosis was identified on radiographs of the Between 1997 and 2003 a single surgeon (JKS) performed 17
ankle. Of the 40 patients available for analysis, 38 fusions on 37 tibiotalar arthrodeses in 16 patients using a custom 3.5 mm low
patients were assessed by the senior author, and the remaining 3 contact dynamic compression (LCDC) plate which was custom
patients completed telephone questionnaires. Assessments done fashioned into a blade plate prior to surgery. A lateral approach
at 6, 12, 26 and 52 weeks, then yearly Radiographs taken at each with partial fibulectomy was employed to achieve tibiotalar
visit to assess alignment and fusion Evaluation tools: AOFAS arthrodesis. The study group consisted of 16 patients, 17 arthritic
ankle-hindfoot scale and SF-36 forms Statistical analysis ankles, 10 men, and six women with an average age of 54 years
performed using SPSS 12.0 (Chicago, IL) 40 patients (41 ankles) (27 to 71). Results: Sixteen patients with 17 ankle arthrodesis
completed the study 39 of 41 ankles went on to union after were available after a mean follow up period of 37.3 months.
index surgery (as verified by radiographs demonstrating obliter- There were no post-op wound complications or infections. There
ation of the ankle joint space with trabecular continuity), for a were no nonunions identified within the study. The mean
union rate of 95% Mean time to union was 14 weeks (range: 6 American Orthopaedic Foot and Ankle Society (AOFAS) hind-
to 46 weeks) 4 patients had delayed unions beyond 6 months, 2 foot score was 78.25 (range 65-92). The average time to fusion
of which progressed to non-union at one year (which were then was 3.9 months. Tibiotalar arthrodesis using a custom blade plate
revised and went on to heal) Mean AOFAS ankle-hindfoot scores and a lateral approach is a reliable therapy for aseptic post-trau-
improved from 57.6 (range: 32 to 69) preoperatively to 80.6 matic arthritis.
(range: 64 to 95) postoperatively. All patients had improved
pain and function scores. Mean physical functioning component
of the physical summary score (PCS) of the SF-36 was 56, which
correlated with scores for healthy individuals of the same age in
the general population. A correlation was found between the SF-
36 PCS and the AOFAS score (r2=0.64). 38 of 41 ankles had
acceptable radiographic alignment 2 ankles were in 7 degrees of
varus, one was in 12 degrees of valgus Dorsiflexion/ plan-

488 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 489

PAPER NO. 063 reported in the orthopaedic literature. As this operative proce-
The Use of a Modified Locking Plate to Achieve dure is studied further, it may continue to hold promise as a
means of achieving TTC arthrodesis.
Tibiotalocalcaneal Arthrodesis
Jamal Ahmad, MD, Philadelphia, PA (n) PAPER NO. 064
Aidin Eslam Pour, MD, Philadelphia, PA (n) Revision Tibiotalar Arthrodesis Using Ring External
Steven M Raikin, MD, Philadelphia, PA (n) Fixation
Abstract: Different types of internal fixation have been used to
Joseph Brian Wilson, MD, Durham, NC (n)
obtain tibiotalocalcaneal (TTC) arthrodesis which include blade
plates and intramedullary nails. The authors have evaluated the Robert D Fitch, MD, Durham, NC (n)
use of an inverted 3.5 mm LCP proximal humerus locking plate James Albert Nunley II, MD, Durham, NC (n)
(PHILOS plate, Synthes, Paoli, PA) to achieve a TTC fusion via Mark E Easley, MD, Durham, NC (n)
multidirectional fixed angle device fixation. The purpose of this Abstract: This study reports the outcome of revision ankle
study is to retrospectively examine clinical and radiographic arthrodesis using ring external fixation in patients that had failed
fusion rates from using a 3.5 mm LCP proximal humerus prior ankle arthrodesis using internal fixation. Twenty-two
locking plate through a lateral transfibular approach to obtain a consecutive patients underwent revision tibiotalar arthrodesis
TTC fusion. Between April 2003 and November 2005, seventeen using ring external fixation. All patients had at least one prior
patients underwent eighteen TTC arthrodeses with a PHILOS attempt at arthrodesis using internal fixation. External fixation
plate through a lateral transfibular approach. Eleven patients was maintained for an average of 15 weeks (range 12 to 44
were male and the remaining six were female. The patients were weeks). Union (time to removal of external fixation) was indi-
aged between 22 years and 72 years with the mean age being cated by bridging trabeculation at the arthrodesis site in three
54.2 years. Five, eleven, and one patient had the fusion done on standard radiographic views. Pre-and post-operative AOFAS
their right, left, and both legs respectively. Preoperative diag- ankle-hindfoot scores were used to assess functional outcome.
noses included six patients with Charcot arthropathy, four with All 22 patients were available for follow-up at an average of 51
neuromuscular disease, four with post-traumatic arthritis, two months (range 15 to 62). The average AOFAS ankle-hindfoot
with post-collapse talar osteonecrosis, and two with inflamma- score improved from 26 preoperatively (range 0 to 45) to 64
tory arthritis. Fifteen of the total seventeen patients (88.2%) had points at final follow-up (range 0 to 87 points). Tibiotalar fusion
radiographically osteopenic bone on preoperative evaluation. was achieved in 19/22 patients (86%). The three patients with
Ten patients did not have previous surgery on their involved leg, persistent nonunions had talar AVN (1) and unresolved
six had undergone one prior surgery, and one had three previous osteomyelitis (2). Thirty-four minor complications (pin tract
operations. Patients were followed up from 8 months to 3 years infections (24), broken pins (3), cellulitis (7)) were managed
and 2 months with the mean being 20.6 months. In regards to effectively with local wound care, oral antibiotics, and/or pin
the operative procedure, a standard transfibular approach with removal. Four major complications (deep infection (2), wound
preparation of the joint surfaces was performed. A PHILOS plate dehiscence (2)) were surgically addressed while maintaining

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

was then inverted and applied to the bones using dynamic compression at the arthrodesis site by external fixation. Three
compression across the joints. The proximal portion of the patients had symptomatic malunions: varus (1), valgus (1),
PHILOS plate was fixed to the calcaneus and talus with locking equinus (1). Union rates and results of revision ankle
screws in multiple planes of fixation. The distal portion of the arthrodesis using ring external fixation are comparable to those
plate was fixed to the distal tibia through a combination of reported for revision arthrodesis with internal fixation.
cortical and locking screws. Three patients (17.6%) received iliac
crest bone autograft and one patient (5.9%) received femoral PAPER NO. 065
head allograft with their TTC fusion. Fusion was achieved clini- Preliminary Review of Hemodialysis Effect on
cally and radiographically in 16 of the 17 patients (94.1%) and
17 of the 18 arthrodeses (94.4%) with a mean time to fusion of
Perfusion Pressure in Diabetic and Nondiabetic
20.6 weeks. All 16 of these patients had acceptable alignment of Patients
the ankle and hindfoot without motion at the fusion site. The David B Kay, MD, Akron, OH (n)
mean AOFAS score increased from 14.6 of 100 preoperatively to Dawn C Sues, RN (n)
76.7 of 86 (equivocal to 89.2 of 100) at the time of final follow- Nairmeen Haller, PhD (n)
up for these patients. These 16 patients were without pain and Brian Cabral, MD (n)
satisfied with the postoperative outcome at their latest follow-
Monica Cating, MD (n)
up. One patient who had brittle diabetes and chronic renal
failure necessitating regular hemodialysis went on to develop a Suzanne Ray, MD, Temple, TX (n)
nonunion of his TTC fusion. The patients in this study had a Anthony Marinos, MD (n)
wide variety of conditions such as advanced age, post- Gina Slipka-Marinos, MD (n)
menopausal state, diabetes, Charcot arthropathy, disuse Abstract: Patients with diabetes are at greater risk of developing
osteopenia, and renal osteodystrophy that rendered the bone at chronic foot wound. In 2002, approximately 83% of all diabetic
their ankle and subtalar joints osteopenic and/or osteoporotic. patients with end stage renal disease required hemodialysis.
This study demonstrates that using a modified locking plate for There is a concern that hemodialysis may disrupt perfusion of
a TTC arthrodesis results in a high rate of bony union and align- the extremities causing impairment of wound healing. Current
ment correction stability. The advantage a locking plate has over laser Doppler technology provides the opportunity to identify
previously described arthrodesis methods such as a blade plate changes in vascular performance in a non-invasive fashion. The
is that a locking plate provides fixation by the plate itself acting objective of this study was to identify differences in perfusions
as a fixed angle device and the locking screws placed in different pressures between diabetic and non-diabetic patients. Patients
directions acting as multiplanar fixation. The use of a locking requiring hemodialysis and meeting inclusion criteria were
plate to achieve a TTC arthrodesis has not been previously included. Serial peripheral perfusion and oxygenation measure-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
489
PPSE 07:Layout 1 1/12/07 1:41 PM Page 490

ments are obtained before, midway, and at the conclusion of the PAPER NO. 067
dialysis session using a transcutaneous laser Doppler system. Percutaneous Perforations for the Treatment of
Preliminary data were assessed using the Student’s t test. The
data indicate a significant difference between toe perfusion pres- Osteonecrosis of the Ankle
sures of diabetic and nondiabetic patients (n=23 and 12 meas- German A Marulanda, MD, Baltimore, MD (n)
urements, respectively) during (p<0.01) and immediately Michael A Mont, MD, Baltimore, MD (a, e – Stryker)
following (P<0.05) the dialysis session. No difference was Thorsten M Seyler, MD, Baltimore, MD (n)
detected in toe pressure, skin perfusion measurements, or the Ronald Emilio Delanois, MD, Lutherville, MD (n)
oxygenation measurements prior to the dialysis session. Our
Abstract: Core decompression has historically been used during
data suggest that hemodialysis may significantly affect perfusion
the early stages of osteonecrosis of the ankle as a treatment
to the lower extremities in diabetic patients. Trends from these
method to decrease pain and defer the eventual collapse of the
data indicate the need to continue this study as originally
joint. Originally, this procedure was described using large diam-
designed. Consequently, reassessment of the hemodialysis
eter trocars. The multiple locations of the lesions (such as the
protocol or the techniques used to heal diabetic wounds may be
distal tibia and fibula, the talar dome, the calcaneus, and/or the
justified in order to improve the chances of a successful treat-
metatarsals) and the relative small affected bones (compared to
ment. This study allows clinicians to better understand the effect
the femoral head and distal femur) made this procedure techni-
of hemodialysis on distal perfusion, and subsequently deter-
cally difficult. The investigators report on the treatment of
mine to what extent the periphery may be compromised.
osteonecrosis of the ankle with a new technique using multiple
small percutaneous 3-mm perforations. Between September,
PAPER NO. 066
2002 and May, 2004 the senior author treated 44 symptomatic
The Efficacy of Popliteal Regional Block Anesthesia ankles affected with osteonecrosis using the multiple perforation
in Foot and Ankle Surgery technique. The series included 31 patients (23 women, 8 men)
Sheeraz Qureshi, MD, New York, NY (n) who had a mean age at the time of surgery of 42 years (range, 17
to 61 years). All the procedures were performed using a 3-
Rachel Y Goldstein, BA (n)
millimeter Steinman pin technique. Radiographic outcome was
Dov Kolker, MD, Old Westbury, NY (n) assessed during post-operative clinical visits using plain x-rays
Steven Bennett Weinfeld, MD, New York, NY (n) and magnetic resonance imaging. Clinical outcome was assessed
Meg Rosenblatt, MD (n) post-operatively using the AOFAS (American Orthopaedic Foot
Abstract: Despite a trend towards regional anesthesia for and Ankle Society) score. Progression of the disease (defined as
orthopaedic procedures, there is resistance to the use of popliteal evidence of subchondral collapse or AOFAS score <=80 points)
regional block anesthesia (PRBA) for foot/ankle surgery because was correlated with demographic variables such as associated
of concerns about block failure and potential complications. The risk factors, prior surgical procedures, size, and location of the
purpose of this study was to determine if PRBA is a safe and lesions. Ankle arthrodesis was avoided in 93% of the cases (41
effective form of anesthesia for foot and ankle procedures. A of 44 ankles) at a mean follow-up of 3.6 years (range, 2 to 5
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

retrospective review was performed of 372 consecutive patients years). Forty of 44 ankles (91%) had a successful clinical
undergoing foot/ankle surgery with PRBA in a tertiary-care, outcome (AOFAS score e 80 points). The AOFAS score for the
university-based practice with an anesthesiology residency entire series increased from a preoperative mean of 41 points
program between October 2002 and May 2006. Data including (range, 34 to 55 points) to a postoperative mean of 88 points
surgical procedure, occurrence of block failure, and presence of (range, 51 to 100 points). The AOFAS score for the series
complications was recorded for all patients. PRBA (block of the excluding the three ankles that required arthrodesis increased
sciatic nerve in the popliteal fossa with the addition of a femoral from a preoperative mean of 41 points to 91 points postopera-
nerve block in the groin or saphenous nerve block at the medial tively. The three cases that required ankle arthrodesis presented
knee) using a peripheral nerve stimulator technique was initially with osteonecrosis of multiple bones about the ankle
planned for all patients. A total of 364 patients (97%) had a (talus, calcaneous, distal tibia and fibula) and two of these cases
successful block. Eight patients required conversion to general had an HIV infection as an associated risk factor for
anesthesia because the block was inadequate. Success of the osteonecrosis. All but 8 patients presented signs and symptoms
block was independent of type or length of surgery. There was of osteonecrosis in other joints (hip, knee, shoulder) and this
one case of postoperative neuralgia that resolved after seven had a negative correlation with outcome. There were no compli-
days. There were no cases of popliteal artery injury, infection, cations from the procedures, which were all performed as outpa-
seizure, or cardiopulmonary compromise. PRBA avoids the risks tient surgeries. The percutaneous perforations technique appears
of general or spinal anesthesia and provides effective anesthesia to be a low-morbidity method of relieving symptoms and defer-
below the knee for foot/ankle surgery. When administered by a ring ankle arthrodesis (or other invasive procedures) in patients
dedicated and skilled anesthesia team, PRBA is a safe and reli- with symptomatic osteonecrotic ankles. The authors believe that
able technique that has an excellent success rate with a low rate these results support the need for a multicenter-randomized
of complications. study comparing minimally invasive treatment options for
osteonecrosis about the ankle.

490 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 491

PAPER NO. 068 PAPER NO. 070

A Prospective Randomized Trial of Two Mobile Proprioception in the Total Ankle: A Direct
Bearing Total Ankle Replacement Implant Designs Comparison of the Operative versus Nonoperative
Viren Mishra, MD, Altrincham, United Kingdom (n) Ankle
Peter L R Wood, MBBS FRCS, Wigan, United Kingdom (n) Gary Wayne Stewart, MD, Mcdonough, GA (n)
Abstract: We report a prospective randomised trial of 200 total Stephen F Conti, MD, Pittsburgh, PA (a – DePuy)
ankle replacements using either Buechel-Pappas (B-P) or Mark C Miller, PhD, Pittsburgh, PA (n)
Scandinavian Total Ankle Joint Replacement (STAR). BP
Derek Dazen, PhD (n)
implants were either nitrided titanium (Endotec) or cobalt
Abstract: The use of Total Ankle Arthroplasty (TAA) for the treat-
chrome (Wright Cremescoli). There were106 men and 94
ment of end-stage ankle arthritis continues to be an area of
women (mean age 65 years; 22- 85). 69 patients had inflamma-
interest for orthopedic surgeons and, in appropriate circum-
tory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14
stances, is an alternative to arthrodesis. Short and intermediate
STAR) had a preoperative varus/valgus deformity 20 degrees or
term clinical studies show promising results. However, clinical
more. Mean follow-up was 48 months (36-72) Ten patients had
outcome and x-ray studies do not adequately assess function
died from unrelated cause with satisfactory final outcome assess-
which may ultimately determine the best treatment for a given
ment. Thirteen ankles (4 STAR, 9 B-P) required revision surgery.
patient. Several current studies are attempting to compare
The causes of failure were: early deep infection (1 STAR), recur-
normal ankles, total ankle arthroplasty and ankle arthrodesis
rent deformity (1 STAR, 4BP) aseptic loosening (1STAR, 4 BP),
through various biomechanical models. No study has assessed
implant failure (1STAR, 1 BP). Six revised ankles (5BP, 1STAR)
the proprioceptive control of a total ankle. We believe that
had preoperative varus/valgus deformity of 20 degrees or more.
patients with TAA will have more proprioceptive defects than the
AOFAS score for pain improved from 0 to 35 and for function
unaffected contralateral ankle. Fifteen patients (30 feet) with a
from 30 to 43. There was no difference between the two groups.
unilateral total ankle replacement were tested using a proprio-
Preoperative range of movement was predictive of the final range
ception testing device (PTD). The PTD has previously been vali-
of movement. Radiographic assessment showed that 30 patients
dated and has been used to quantify the functional abilities of
(17BP, 13 STAR) had recurrent deformity (edge loading) as
patients with TAA. All 15 patients have at least 2 years of clinical
shown by the UHMWPE insert no longer articulating congru-
follow-up post TAA (mean 3.5 years). After obtaining informed
ently with the metallic components. 14 ankles (8BP, 6 STAR)
consent, the patients were placed into our PTD. The nonopera-
from this group had preoperative deformity of 20 degrees or
tive/uninvolved ankle was tested in the sagittal and coronal
more. Patients with severe preoperative deformity had a signifi-
planes. The operative ankle was measured similarly. Our results
cant evidence of edge loading and failure resulting in revision
show that the TAA side had proprioceptive function equivalent
surgery. BP replacements failed more frequently than STAR
to the uninvolved side, within the parameters tested, allowing us
replacements but most BP failures were in ankles with severe
to infer that patients with TAA perceive their ankles similarly to
preoperative deformity.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

their contralateral normal ankle. In conclusion, TAA has reason-
PAPER NO. 069 able clinical data to support its use; our study adds propriocep-
tion data to support the use of total ankles in patients with
Conversion of Ankle Arthrodesis into Total Ankle end-stage ankle arthritis.
Arthroplasty
Markus Knupp, MD, Liestal, Switzerland (n) PAPER NO. 071
Beat Hintermann, MD, Liestal, Switzerland (n) Prospective Outcome Study on the Agility Total
Abstract: Arthrodesis of the ankle joint may lead to secondary Ankle Replacement: Minimum 3 Year Follow-Up
changes in the neighboring joints and painful restriction of J Chris Coetzee, MD, Eagan, MN (e – DePuy)
motion. We report on a prospective study of 19 consecutive total
Abstract: Early attempts at total ankle arthroplasty resulted in
ankle replacements after ankle arthrodesis or attempted fusion
disappointing results, and subsequent loss of interest in ankle
of the ankle. Eighteen patients (19 ankles) were included in the
replacement. However, alternative methods of treatment for
study. The ankles were converted into a total ankle arthroplasty
ankle arthritis have associated problems and complications. This
after ankle arthrodesis (17 ankles) or attempted fusion (two
has stimulated resurgence in the search for a successful ankle
ankles). A current three-component ankle prosthesis was used in
replacement. Currently, in the United States, the Agility implant
all patients. At the latest follow-up after 42 months (range 24 to
(DePuy, Warsaw, Indiana) is the most widely used ankle pros-
74), the AOFAS hindfoot score increased from preoperatively
thesis. Newer techniques and a better understanding of ankle
33.6 points to 66.5 points. The average clinically measured ROM
mechanics has led to improved short and mid-term outcomes.
of 24.2° amounted to 52.0% of the range of the contralateral
Most recently, Saltzman, Alvine et al reported their 7 to 16 year
ankle. Our results show patient satisfaction regarding pain relief
follow-up for the early version of the Agility implant in 132
and regained function. The bone healing capacity in the ankle
arthroplasties. 11% of patients required a revision of their
joint seems to be sufficient for arthroplasty and the achieved
implant or conversion to ankle fusion. The purpose of this study
stability in the joint was found to provide good function, even
was to prospectively evaluate and document the results of the
after arthrodesis. The results of the present study were slightly
Agility total ankle replacement at 3 year follow-up. From
inferior to studies with primary arthroplasty. We believe that
October 1999 through October 2004, 172 ankles patients
arthroplasty of the ankle joint represents a valuable alternative to
underwent an Agility total ankle replacement. Prospective data
current treatment options of painful sequels of longstanding
was collected before surgery, at 6 months, one year, and yearly
ankle arthrodesis.
thereafter. The data included AOFAS (American Orthopaedic
Foot and Ankle Society) Ankle and Hindfoot scale, the MFA
(Muscluoskeletal Functional Assessment Injury and Arthritis
Survey), the Visual Analog Pain Scale, self reported patient satis-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
491
PPSE 07:Layout 1 1/12/07 1:41 PM Page 492

faction, and standardized X-rays. Fifty five percent were done for recruited on a consecutive basis as they presented to the lead
post-traumatic DJD, 41% for primary DJD, and 2% RA and 2% author’s clinic and they met the study’s inclusion criteria. Three-
for AVN. Fifty eight percent had al least one previous surgical dimensional gait analyses were performed before ankle replace-
procedure done on the ankle 113 of 172 patients are now more ment surgery and then every year after surgery out to 6 years. Data
than 3 years past total ankle replacement. 19 patients were lost are reported for the most recent analysis (average of 2.91 ± 1.05
to follow-up. The remaining 94 have prospective data, but only years post-operatively, range: 2.0-5.1 years). Velocity significantly
67 had complete data for every interval. This group is included increased postoperatively (p < 0.0001). The most notable effects
in the results. At three year follow-up, the average AOFAS score were demonstrated at the operated ankle itself, with significant
improved from 44 pre-op to 77 at 6months and 79 at 3 years. increases in ankle range of motion during gait (p < 0.0001) and
The average total MFA score decreased (improved) from 38 to increases in peak sagittal ankle joint power at push-off (p <
18. Visual Analog Pain scores decreased from 8 to 2. Ankle range 0.0001). This is the first study, to the best of our knowledge,
of motion improved on average by 5 degrees. 95% of patients which prospectively examines the effect on gait of the newest
were satisfied with the surgery. The overall complication rate was generation of total ankle arthroplasties, with a minimum two-
24%. (15 patients) Of that 55% (8 patients) were serious, year follow-up. It demonstrates objective improvements in gait
requiring a major second operation. Peri-operative complica- function when compared to pre-operative condition and shows
tions were usually not serious, but late complications almost a superiority of gait function when compared to the results of
invariably led to further surgery. The most common early previous studies of gait analysis following ankle arthrodesis.
complication was non-union of the syndesmoses. (4 cases) Two
revisions were done, and 2 ankles were fused. Of the 113 patients PAPER NO. 074
more than 3 years after surgery incomplete data were available Infection Rate After Primary Ankle Replacement:
on 46 patients. In this group there were a further two fusions, 3
syndesmoses non-unions and one amputation. In properly
A Cohort Study of 386 Consecutive Ankle
selected patients, the Agility Total Ankle Replacement shows an Replacements
improvement in pain relief and function at minimum 3 year Michaela Maria Schneiderbauer, Uster, Switzerland (n)
follow-up. However, there is a significant complication rate. Andrej Trampuz, MD (n)
Ankle replacements are not simple. The patients that do well Andreas Widmer, MD (n)
generally do very well, but the patients with complications are
Beat Hintermann, MD, Liestal, Switzerland (n)
difficult to salvage. The early results are promising, but longer
term follow-up is needed to further assess outcomes. Abstract: Ankle replacement is increasingly used for degenerative
arthritis, however data on infection rate after primary implanta-
PAPER NO. 072 tion are limited. Between 1996 and 2004, all patients with ankle
prosthesis implantation at our institution were prospectively
◆200 STAR Total Ankle Replacements: A Mid-Term included and followed-up at 6 weeks, 3 months, 6 months, and
Follow Up Study annually thereafter. Ankle prosthetic infection was diagnosed by
tissue cultures, collected during revision surgery. During the study
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

Hari P Prem, MBBS, FRCS (n)

Peter L R Wood, MBBS FRCS, Wigan, United Kingdom (n) period, primary ankle prostheses were implanted in 371 patients
(386 ankles), of whom 12 (3.1%) subsequently became infected.
Abstract: 200 total ankle arthroplasties (TAA) in 119 rheumatoid
4 of 12 infected patients had a previous ankle infection or an
and 81 OA patients with average age 61 years (range 18 - 83)
open fracture. The median time from primary implantation to
were performed between 1993 and 2000 using the STAR pros-
infection was 9 months (range, 0 days-4 years); 5 infections were
thesis. No patients have been lost to follow-up. Pre-operatively
early (<3 months postoperatively) and 7 were late. Predominant
34 OA ankles had anterior subluxation of the talus as deter-
pathogens were Staphylococcus aureus (n=4), coagulase-negative
mined by the Tibio-Talar-Ratio (TTR described by Tochigi AAOS
staphylococci (n=3), anaerobes (n=2) and mixed organisms
2005) being 2 SD below normal. 24 ankles failed and were
(n=3). All patients received antibiotic therapy for >6 weeks. As
revised at 1 to 108 months following surgery. The reasons were
surgical modalities implant retention with irrigation and
early infection 1; intraoperative or late fracture of the medial
débridement (n=6), antibiotics only (=2), liner change (n=2),
malleolus 3; broken polyethylene bearing 1; aseptic loosening
tibial component exchange (n=1), and two-stage exchange (n=1)
14 and progressive malalignment 5. The survival is 93% at 5 and
were chosen. Three patients needed flap coverage. All infected
79 % at 10 years. The AOFAS score for pain improved from 0 to
patients were clinically free of infection at last follow-up. The
35 and function from 31 to 40. TAA with the STAR prosthesis
infection rate after primary ankle replacement (3.1%) was higher
gives pain relief and improved function. Radiographic measure-
than reported after primary knee and hip prosthetic replacement.
ment using the TTR showed that the talus may be restored to a
In patients with higher risk for infection, tissue biopsies should
normal position following TAA. Survival figures do not yet
be collected at the time of prosthetic implantation to diagnose
match those of the knee and hip but are very similar to those
residual low grade infection. In selected patients, soft tissue
reported for the Agility.
conditions might prohibit the implantation of ankle prosthesis,
PAPER NO. 073 even if the bony circumstances would suggest.

Results of Gait Analysis after S.T.A.R. Total Ankle

Arthroplasty
James White Brodsky, MD, Dallas, TX (n)
Fabian E Pollo, PhD, Dallas, TX (n)
Brian Baum (n)
Abstract: A prospective gait analysis study was performed on 49
patients who were enrolled in an FDA clinical trial of the
Scandinavian Total Ankle Replacement (STAR). Patients were

492 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 493

PAPER NO. 075 should be given towards plating the fibula in addition to
Sports Activity with Total Ankle Arthroplasty syndesmotic fixation, as this can provide a stronger initial
construct when compared to syndesmotic fixation alone.
Victor Valderrabano, MD, Basel, Switzerland (n)
Andre Leumann, MD (n) PAPER NO. 167
Geert Pagenstert, MD, Liestal, Switzerland (n) Triple Arthrodesis In Rheumatoid Arthritis-
Monika Horisberger, MD (n)
Beat Hintermann, MD, Liestal, Switzerland (n)
A Retrospective Long-Term Study
Abstract: Increasing number of patients is treated for severe ankle Anne Skoog, MD, Stockholm, Sweden (n)
osteoarthritis (OA) by total ankle arthroplasty (TAA). The Markus Knupp, MD, Liestal, Switzerland (n)
purpose of this study was to quantify the amount and type of Hans Tornkvist, Huddinge, Sweden (n)
sports activity among TAA patients. Clinical prospective study of Sari Ponzer, MD, PhD, Associate Prof, Stockholm, Sweden (n)
147 patients treated with TAA (HINTEGRA) for end-stage ankle Abstract: To assess the long term results of triple arthrodesis in
OA (152 ankles); average age 59.6 years (28-86y). patients with rheumatoid arthritis we retrospectively focused on
Documentation of history, satisfaction, clinical examination, fusion rate, compensatory arthritis of the adjacent joints, clinical
AOFAS ankle score, radiological assessment, percent, type, and outcome and patient satisfaction. Between 1990 and 1998, 28
level of sports activity. Mean follow-up was 2.8 years (2-4y). patients with rheumatoid arthritis were managed with a total of
Preoperative diagnosis was posttraumatic OA in 115 cases 32 triple arthrodeses. Of the 28 patients, 20 (24 cases) had been
(76%), primary OA in 21 cases (13%), and systemic arthritis in followed for 5.2 years (range, 4 to 7 years) and formed our study
16 cases (11%). Excellent and good satisfaction was reported in group. Fusion was achieved with rigid staple fixation and autol-
126 cases (83%). 105 ankles (69%) were completely pain free. ogous bone transfer. Assessment for all patients included plain
The average ROM was clinically 35° (10°-55°). The overall radiographs, Ct scans and different clinical outcome measures.
AOFAS score improved from 36 points (10-74) preoperatively to Complications were limited to superficial wound healing prob-
84 points (28-100) at follow-up. Sports active patients showed a lems in eight patients (eight cases). No revision surgery was
significant higher AOFAS score then sports-inactive patients: 88 necessary in any of the patients. Radiographically all feet showed
vs. 71 points (p<0.05). 56% of the patients (85 cases) were fusion. Progression of arthritis was found in 17 cases, mostly in
sports-active with a TAA: moderate 41 (27%), normal 34 the midfoot. The Short Form-36 (SF-36) scores were generally
(22.4%), high 10 (6.6%), elite none (0%). The most frequent lower compared to normal population. The ankle-hindfoot
sports activities were: hiking (53%), biking (46%), swimming score of the AOFAS averaged 70 points (range, 40 to 94 points).
(34%), fitness (12%), skiing (8%), golfing (6%). 13 ankles (9%) All patients stated that they would have the procedure again
had to be revised. The majority of patients with TAA are sports- under similar circumstances. Triple arthrodesis for treatment of
active, in average on a normal sports level. The sports-active hindfoot involvement in rheumatic arthritis is effective in
group shows better overall results as the inactive. The new TAA relieving pain and improving functional deficits and high fusion
generation is a promising treatment option for severe ankle OA. rates can be expected. There is, however, a high risk for consecu-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

tive arthritis of the neighbouring joints, especially in the
PAPER NO. 166 midfoot.
Midshaft Fibula Fractures with Syndesmotic
PAPER NO. 168
Disruption: Should We Plate the Fibula?
Jason Ho, MD, Brookline, MA (b – Synthes)
Low Tibial Osteotomy for Varus Type Osteoarthritis
Yupeng Ren, MS (a – NIH, b – Synthes) of the Ankle
Armen S Kelikian, MD, Chicago, IL (b – Synthes) Yasuhito Tanaka, MD, Kashihara, Japan (n)
Arash Aminian, MD, Seattle, WA (b – Synthes) Yoshinori Takakura, MD, Kashihara, Japan (n)
Iain Charnley, BS (b – Synthes) Tsukasa Kumai, MD, Ikoma, Japan (n)
Li-Qun Zhang, PhD, Chicago, IL (a – NIH, b – Synthes) Shinji Isomoto, MD, Kashihara, Japan (n)
Abstract: A unique subset of syndesmotic injuries includes mid- Kouichi Narikawa, MD, Kashihara, Japan (n)
diaphyseal fibula fractures with deltoid and syndesmotic liga- Koji Hayashi, MD (n)
ment disruption. Whether to use syndesmotic fixation only Akira Taniguchi, MD, Kashihara, Japan (n)
versus syndesmotic fixation along with fibular plating is contro- Kazuya Sugimoto, MD, Hachijo, Nra-shi, Japan (n)
versial. The purpose of this study is to compare the biomechan- Abstract: Varus type osteoarthritis of the ankle is characterized by
ical strengths of these two constructs Eight pairs of human varus deformity of the articular surface at the distal end of the
cadaveric legs divided into two groups. In Group I, the left legs tibia. We have applied low tibial osteotomy in order to correct
were fixed with a single syndesmotic screw. In Group II, the right varus deformity. The purpose of this retrospective study was to
legs received this syndesmotic fixation in addition to plating of assess the results and determine the indications for this opera-
the fibula. After testing for rotational stability in the repaired tion. Valgus osteotomies were done with an open wedge tech-
condition, each specimen was cyclically loaded in plan- nique. We performed follow-up examination of 25 consecutive
tarflexion/dorsiflexion and subsequently loaded to failure in patients (26 feet) who had operated between 1987 and 2002. All
external rotation. Load to failure, energy, stiffness, and restora- patients could be investigated. All were females aged 37-76 years
tion of rotational stability were all found to be significantly (mean, 54 years). The postoperative period ranged from 2 years
higher for the plate and syndesmotic fixation repair technique as 3 months to 18 years (mean, 8 years 3 months). Clinical and
compared to the syndesmotic fixation only technique. radiographic evaluation was performed. Nineteen ankles
Furthermore, the restored stability was reduced significantly after showed excellent or good clinical results. Mean clinical scores of
cyclic loading in Group I, but not in Group II. Consideration pain, walking, and activities of daily living were significantly
improved but there was no change in range of motion. In ankles

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
493
PPSE 07:Layout 1 1/12/07 1:41 PM Page 494

which were radiographically classified as stage 2 (Narrowing of asymmetric posttraumatic OA were treated with distal tibial
the joint space medially) and stage 3-a (Obliteration of the joint osteotomy and additional bony and soft-tissue procedures.
space only at the medial gutter), the loss of joint space recovered. Patients were investigated clinically and radiographically by a
On the other hand, recoveries were observed in only two of 12 standardized protocol. The OA process was in the medial (n =
ankles which were classified as stage 3-b (Obliteration of the 13; 37%) or lateral (n = 21; 63%) ankle. While distal tibial
joint space advancing to upper surface of the talar dome). This osteotomy was done in all cases, additional bony and soft tissue
study indicated that intact cartilage on the upper surface of the procedures were performed in 32 patients (91%). Recurrent
talar dome is necessary for supporting load on the joint. A low deformity was noted in two ankles (6%), being both ankles
tibial osteotomy should be indicated for stage 2 or 3-a. successfully revised. Three ankles (9%) were revised to total
ankle arthroplasty between one to two years. At a mean follow-
PAPER NO. 169 up of 4.8 years (range, 3 to 10.5 years), the outcome correlated
Complication Rates After Ankle Fracture in the with preoperative pain (r=0.66; p<0.001), preoperative ankle
ROM (r=0.43; p=0.01), achieved tibiotalar joint space paral-
Elderly: Surgical vs Nonperative Treatment lelism (r=0.57; p<0.001). Combination of aligning osteotomies
Kenneth J Koval, MD, Lebanon, NH (n) and soft tissue procedures was crucial to achieve a symmetrically
Weiping Zhou, MS, Hanover, NH (n) loaded ankle joint. Reconstructive surgery, as given by the
Jon D Lurie, MD, Lebanon, NH (n) proposed algorithm, might therefore be considered for asym-
Abstract: The purpose of this study was to determine the compli- metric ankle OA, particularly in younger patients to delay fusion
cation rates for ankle fractures in the elderly treated surgically or total ankle replacement.
and compare it to those fracture treated nonoperatively. A 20%
sample of Medicaire Part B claims from years 1998-2000 was PAPER NO. 171
analyzed. The CPT codes for operative and nonoperative treat- Neutral Ring Fixation for High Risk Non-Plantigrade
ment of isolated medial malleolar, isolated lateral malleolar, Charcot Midfoot Deformity
bimalleolar and trimalleolar fractures were identified. The
outcomes evaluated included mortality and rehospitalization at Michael S Pinzur, MD, Maywood, IL
30 days, 6 months, 1 and 2 years, the rate of medical and surgical (e – Depuy Orthopaedics)
complications and the rate of additional surgery at up to 2 years. Abstract: Introduction: Charcot Foot arthropathy imparts a
The predictor variables were either nonoperative or surgical severe negative impact on the quality of life of affected individ-
intervention. Covariates included patient age, sex, race, number uals, often leading to lower extremity amputation. Many of the
and type of medical comorbidities (Charleson index, diabetes, affected patients are morbidly obese, immunocompromised,
peripheral vascular disease) and fracture type. Regression was have complex wounds, or bony infection, making surgical
performed using the above variables. 34,078 ankle fractures were correction and internal fixation difficult. Methods: Twenty-three
identified; 33% of patients were treated surgically. Overall consecutive poor host diabetic adults with midfoot level Charcot
mortality at one and two years was 7.9% and 13.7% with rehos- Foot arthropathy underwent surgical correction of their defor-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

pitalization rates of 45% and 54.2% respectively. Except for 30 mity, with maintenance of the surgical correction with a
days, patients treated nonoperatively had significantly higher neutrally applied three-level ring external fixator. Bony infections
mortality than those treated surgically. However, patients treated were treated with excision of infected bone and culture-specific
with surgery had significantly higher rehospitalization rates all parenteral antibiotic therapy. All were diabetic for greater than
time periods studied. The medical and surgical complication ten years. Seventeenteen used insulin. BMI was 37.41 + 8.49.
rates at all time periods were <2% for both surgical and nonop- Thirteen had open wounds that communicated with bone.
erative treatment. The overall rate for additional surgery at 2 Weight bearing radiographic AP axis was 13.9 + 32.6 degrees,
years was 1.5% with ROH 13.6% for surgical pts, and revision and lateral axis was 16.1 + 17.5 degrees prior to surgery. Results:
ORIF, arthroplasty, arthrodesis, and amputation all <1%. Elderly At a minimum one-year follow-up, 25 of 26 are ulcer and infec-
patients treated surgically after ankle fractures had a significantly tion free, and ambulate with commercially-available depth-inlay
higher rate of rehospitalization but lower mortality than those shoes and custom accommodative foot orthoses. Three devel-
treated nonoperatively. This difference in mortality may reflect oped recurrent plantar ulcers which resolved following exostec-
selection bias in choosing operative treatment for healthier indi- tomy. There were two stress fractures through olive wire pin sites,
viduals. The overall complication rate and need for revision which resolved with protected bracing. The radiographic AP axis
surgery were low regardless of treatment. Based on these results, was corrected to 3.7 + 10.7 degrees, and lateral to 9.6 + 11.5
treatment selection for ankle fractures in the elderly should not degrees following surgery. Discussion: High risk, morbidly
be based on fear of operative complications. obese, poor host diabetics with severe Charcot foot deformity
can achieve correction of the deformity with a minimal risk for
PAPER NO. 170 morbidity following surgical correction of deformity and main-
Realignment Surgery of Posttraumatic Asymmetric tenance of alignment with a neutrally applied ring external
fixator.
Ankle Osteoarthritis - 3 to 10 Years Follow-up
Geert Pagenstert, MD, Liestal, Switzerland (n)
Beat Hintermann, MD, Liestal, Switzerland (n)
Alexej Barg, MD (n)
Robert Kilger, MD (n)
Andre Leumann, MD (n)
Victor Valderrabano, MD, Basel, Switzerland (n)
Abstract: The debate about surgical treatment of a symptomatic
osteoarthritic ankle (OA) continues to be controversial. Thirty-
five consecutive patients (age 43 years; range, 26-68 years) with

494 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 495

PAPER NO. 172 other proximal procedures in sawbones. We reviewed the results
Patients with End Stage Ankle and Hip Arthritis of thirty-four total cases of moderate to severe hallux valgus
deformities corrected with the crescentic and Mau osteotomies
Have Similar Poor Health-Related Quality of Life of the first metatarsal combined with a distal soft-tissue proce-
Mark Glazebrook, MD, Halifax, Canada (a – DePuy) dure. Follow-up was possible in thirty-four cases. There were ten
Timothy Rudolf Daniels, MD, Toronto, Canada cases in the crescentic group with an average follow-up 104.6
(a – Canadian Orthopedic Foundation) days and twenty-four cases in the Mau group with an average
Michael Dunbar, MD, PhD, Halifax, Canada follow-up of 118 days. Pre-operatively, the mean first inter-
(a – Wright Medical, Zimmer, DePuy, a, e – Stryker,) metatarsal and hallux valgus angles in the crescentic group were
17.5Ú and 35.4Ú respectively and 17.6Ú and 31.3Ú respectively
Johnny T Lau, MD, Toronto, Canada (e – Zimmer, Biometric)
in the Mau group. Post-operatively, the IM and HV angles were
Ross K Leighton, MD, Halifax, Canada corrected to 11.70Ú± 3.12 and 18.90Ú± 9.62 in the crescentic
(a – Stryker, DePuy, Smith & Nephew, Wright Medical, group and 10.00Ú± 2.43 and 12.96Ú± 7.15 in the Mau group
AO North America, e – Smith & Nephew, DePuy, Etex) with no statistical significance. Complications included eleva-
Murray J Penner, MD, Vancouver, Canada (n) tion (Crescentic 7, Mau 2), non-union (Crescentic 5, Mau 1),
Alastair S E Younger, MD, Vancouver, Canada revision surgery (Crescentic 0, Mau 1), hardware into the tarso-
(a – Biometric, b – Zimmer, DePuy, e – Zimmer) metatarsal joint (Crescentic 3, Mau 0), and transfer lesions
Kevin J Wing, MD, Vancouver, Canada (n) (Crescentic 1, Mau 0). In the crescentic group, 60% experienced
CJ Foote, BSc (n) complications whereas only 37.5% in the Mau group had
complications (p=0.276). Significant differences between the
Abstract: Information on end stage ankle arthrosis (EAA) is
crescentic and Mau groups were with respect to elevation (70%
limited and the amount of pain, reduction in health-related
vs. 8.3%, p=0.001), transarticular hardware in the tarso-
quality of life (HRQOL) and function has not been quantified
metatarsal joint (30% vs. 0%, p=0.02), and non-union (50% vs.
using universal outcome measures. The purpose of this study is
4.2%, p=0.006). The use of the Mau and Crescentic osteotomies
to compare cohorts of patients with EAA and end-stage hip
resulted in good correction of the first intermetatarsal angle in
arthrosis (EHA) who are waiting for surgical treatment. 130
patients with moderate to severe hallux valgus. Although, the
patients with EAA waiting ankle fusion or arthroplasty were
Mau osteotomy avoided complications associated with the cres-
compared to a similar cohort of 130 patients with end stage hip
centic osteotomy such as nonunion, dorsal malunion and intra-
arthritis. All patients completed SF36 questionnaire and statis-
articular hardware placement.
tical analysis were performed to compare each cohort of
patients. All patients with EAA and EHA scored approximately PAPER NO. 174
two standard deviations below normal population scores for all
symptoms and functional SF36 subscales scores. All differences First Web Space Soft Tissue Release in Bunion
between ankle and hip SF36 subscales scores were less than 4 Surgery: Functional Outcomes of a New Technique
points (40% of STD) in both direct and adjusted comparisons.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

Vinod Kumar Panchbhavi, MD, Galveston, TX (n)
Patients with ankle arthritis had significantly worse mental Saul Generoso Trevino, MD, Galveston, TX (n)
health according to the SF36 Mental Component Summary
Jay Rapley, MD, Galveston, TX (n)
Score (MCS) (p= 0.0059), physical limitations with work and
daily activities - role physical score (p= <0.0001), and general Abstract: The purpose of this study is to evaluate a new tech-
health (p= 0.0004). Total Summary SF36, Physical Component nique for distal soft tissue release for hallux valgus correction.
Summary (PCS), bodily pain, vitality, role-emotional, social This procedure provides a step-wise protocol for distal soft tissue
functioning, and mental health subscales were all not signifi- correction in the first web space. An assessment of this new
cantly different between cohorts (p>0.05). The mental and phys- procedure was needed to determine its effectiveness in bunion
ical disability caused by EAA is at least as severe as that observed surgery, as well as its functional outcomes. The authors
in patients with EHA. This is the first study that reports prospec- conducted a retrospective chart review and analysis of 38
tive data documenting the severe impact of EAA on patient pain, subjects (44 procedures) who underwent first web space release
HRQOL, and function. These findings suggest increased utilizing this new technique as part of hallux valgus surgery from
resources should be directed towards treatment of EAA. January 1999 to December 2003. Each subject was also inter-
viewed. A modified Olerud and Molander Score (maximum of
PAPER NO. 173 100 points) was used to asses the functional outcome. The mean
follow-up time was 3.8 yrs. The majority of the study population
A Comparison of the Crescentic and Mau was female (97.7%), and the remaining 2.3% was male. The
Osteotomies in Hallux Valgus Correction mean age was 50.8 (range 24-74).The majority of the patients
Jason P Glover, DPM, Columbus, OH (n) (88.6%) had good or excellent results. The surgical scar was
Christopher Hyer, MD, Columbus, OH (n) hidden between the 1st and 2nd toes in the web space itself. The
Gregory Charles Berlet, MD, Columbus, OH (n) average Olerud and Molander Score was 86.4/100. No hallux
varus deformities resulted from this procedure, there was no loss
Terrence Philbin, DO, Dublin, OH (n)
of correction, and further corrective procedures were unneces-
Thomas H Lee, MD, Columbus, OH (n) sary. The new first web space soft tissue release technique is a
Abstract: In our retrospective study, we compared the results of reliable method to obtain a satisfactory correction and func-
the crescentic and Mau osteotomies of the first metatarsal in the tional outcome following hallux valgus correction surgery. The
treatment of hallux valgus. Historically, the crescentic osteotomy incision in the first web space is hidden between the 1st and 2nd
has been associated with dorsiflexion and shortening of the toes resulting in a scar that is cosmetically superior to existing
metatarsal which pre-disposes the patient to transfer lesions or techniques.
persistence of existing lesions. The Mau and Ludloff osteotomies
have superior intrinsic mechanical stability when compared to

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
495
PPSE 07:Layout 1 1/12/07 1:41 PM Page 496

PAPER NO. 175 this group increased from 35.6 of 100 preoperatively to 71.8 of
Treatment of Hallux-Valgus Deformity in 140 100 and the mean postoperative VAS for pain was 2.38. 26 first
MTP arthrodesis patients were evaluated with a mean follow-up
Patients - Ludloff versus Scarf-Osteotomy time of 30.0 months. No revision arthrodeses were performed in
Oliver Meyer, PhD, Herne, Germany (n) this population. Mean AOFAS Hallux score increased from 35.5
Georgios Godolias, MD, Herne, Germany (n) of 100 preoperatively to 84.1 of 90 (equivocal to 93.4 of 100)
Abstract: Query: The results of chevron osteotomy in moderate which was significantly higher than hemiarthroplasty patients
to severe deformities are not as convincing, depending on the (P=0.006). One patient in this group developed transfer
surgical procedure used. The objective of this study was to metatarsalgia, and was dissatisfied with her result. Mean post-
examine the influence which the choice of surgical procedure operative VAS for this patient population was 0.67 which is less
and thus the osteotomy has on the clinical, radiological and than that of the hemiarthroplasty population to a statistically
pedobarographic results in the forefoot. Method: In a prospec- significant degree (P=0.021). Arthrodesis of the first MTP joint to
tive study, we examined the surgical results of 140 feet treated treat osteoarthritis is more predictable in alleviating symptoms
between August 2004 and March 2005 in our clinic for moderate and restoring function than the BioPro metallic hemiarthro-
Hallux-Valgus deformity. In 70 patients, Ludloff osteotomy and plasty. Patients who received a first MTP fusion had higher func-
in 70 the Scarf osteotomy was selected as the method. The tional scores and satisfaction than those who received a
patients underwent pre- and postoperative clinical, radiological hemiarthroplasty. A higher incidence of long-term failure was
and pedobarographic examination. In addition, patient satisfac- observed in patients that received an MTP hemiarthroplasty,
tion was determined using the Kitaoko Forefoot Score. Results: necessitating conversion of to a fusion in most cases. However,
The mean preoperative IMA was 14.5 º, the Hallux-Valgus angle if an arthroplasty is performed, one distinct advantage of the
(HVA) 31.3º. The IMA could be improved by Scarf osteomy on BioPro metallic hemi-implant over traditional first MTP arthro-
average by 7.6º, by Ludloff osteotomy by 8.1º. With suitable plasties is that the procedure requires minimal bone resection.
plantarisation of the 1st metatarsal head, better and more even Should subsequent conversion to an arthrodesis be required,
pressure distribution in the forefoot could be achieved with both this can be done without great difficulty or structural bone graft.
surgical procedures and the load peaks reduced overall. The
complication rate was somewhat lower overall in the Scarf PAPER NO. 177
osteomy. Conclusion: Both the Scarf osteotomy, and the Ludloff Long-term Results of Extracorporeal Shockwave
ostetomy enable achieving of good results in moderate defor- Treatment for Plantar Fasciitis
mity. The extent to which one procedure should be preferred
over the other could not be determined. Both procedures have Ching-Jen Wang, MD, Kaohsiung, Taiwan (a)
advantages as well as disadvantages. Further attention to this Feng-Sheng Wang, PhD (a)
area of Hallux-valgus surgery is definitely needed to meet the Kuender D Yang, MD, Kaohsiung Hsien, Taiwan (a)
higher demands of the patients. Lin-Hsiu Weng, MD, Kaoshiung Hsien, Taiwan (a)
Jih-Yang Ko, Niao Sung Hsiang, Taiwan (a)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

PAPER NO. 176 Abstract: Extracorporeal shockwave treatment has shown mixed
Comparison of Arthrodesis and BioPro Metallic short-term results for plantar fasciitis. However, the long-term
Hemiarthroplasty of the Hallux first MTP Joint resultsof this new therapeutic modality are not available. This
paper reported the long-term results of shockwave on patients
Jamal Ahmad, MD, Philadelphia, PA (n) with plantar fasciitis with 5 to 6 years of follow-up. This prospec-
Aidin Eslam Pour, MD, Philadelphia, PA (n) tive study consisted of 149 patients (168 heels) with an estab-
Steven M Raikin, MD, Philadelphia, PA (n) lished diagnosis of chronic plantar fasciitis, including 79
Nicholas A Abidi, MD, Santa Cruz, CA (n) patients (85 heels) in the shockwave group and 70 patients (83
Abstract: The purpose of this study is to retrospectively evaluate heels) in the control group. In the shockwave group, patients
the clinical and radiographic outcomes of the long-term results received 1500 impulses of shockwaves at 16 kV to the affected
of the BioPro metallic hemiarthroplasty (Port Huron, MI) and heel in a single session. Patients in the control group received
arthrodesis of the first metatarsophalangeal (MTP) joint over a conservative treatment consisting of nonsteroidal anti-inflam-
3-year period in a practice of two surgeons. Patients with matory drugs, orthotics, physical therapy, an exercise program,
osteoarthritis of the first MTP joint that were treated with either and/or a local cortisone injection. Patients were evaluated at 60
a BioPro metallic hemiarthroplasty or arthrodesis were identi- to 72 months (shockwave group) or 34 to 64 months (control
fied from 1999 through 2004. One surgeon performed the group) with a 100-point scoring system including 70 points for
hemiarthroplasties from 1999 through 2002 while another pain and 30 points for function. The clinical outcomes were
performed the arthrodeses sequentially from 2000 through rated as excellent, good, fair, or poor. Before treatment, patients
2005. Patients who had neuroarthropathy or inflammatory from two groups showed no significant differences in pain and
arthropathy involving their foot were excluded. All identified function scores. After treatment, the shockwave group showed
patients were invited for a follow-up clinical and radiographic significantly better pain and function scores as compared with
examination. Postoperative satisfaction and function were the control group. The overall results were 69.1% excellent,
graded using the American Orthopaedic Foot and Ankle Society 13.6% good, 6.2% fair, and 11.1% poor for the shockwave
(AOFAS) Hallux Scoring System and a Visual Analog Scale (VAS) group; and 0% excellent, 55% good, 36% fair, and 9% poor for
of pain. Data regarding postoperative complications and revi- the control group (P < .001). The recurrence rate was 11% (9/81
sion surgeries were also recorded. Twenty hemiarthroplasty heels) for the shockwave group versus 55% (43/78 heels) for the
patients were evaluated with a mean follow-up time of 79.4 control group (P < .001). There were no systemic or local
months. Five (23.8%) joints required subsequent surgeries due complications or device-related problems. Extracorporeal shock-
to failure of the hemiarthroplasty, four of them converted to an wave treatment appeared to be effective and safe for patients
arthrodesis while the remaining one patient had revision with chronic proximal plantar fasciitis with good long-term
surgery. The mean AOFAS Hallux score of not revised patients in results.

496 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 497

PAPER NO. 178 practical advantages of immediate weight-bearing did not

predispose the patients to a higher complication rate. In partic-
◆High Energy Extracorporeal Shock Wave Therapy ular there was no evidence of tendon lengthening or a higher re-
as a Treatment for Insertional Achilles Tendinopathy rupture rate. On the basis of our findings, we would advocate the
John P Furia, MD, Lewisburg, PA (n) use of immediate weight-bearing mobilisation for the rehabili-
Abstract: The purpose of this study was to determine the efficacy tation of all patients with rupture of the Achilles tendon.
of high energy ESWT for the treatment of adults with chronic
insertional Achilles tendinopathy and to determine if use of a PAPER NO. 180
local anesthesia field block had an adverse effect on outcome. The Effects of Air Exposure and Irrigation on Healing
Thirty-five patients with chronic insertional Achilles of the Achilles Tendon: An Experimental Study
tendinopathy were treated with a single dose of high energy
ESWT (ESWT Group, 3000 shocks, 0.21 mJ/mm2, total energy Yakup Yildirim, MD, Philadelphia, PA (n)
flux density of 604 mJ/mm2). Thirty-three patients with chronic Baransel Saygi, MD, Istanbul, Turkey (n)
insertional Achilles tendinopathy were not treated with ESWT, Cengiz Cabukoglu, MD, Istanbul, Turkey (n)
but instead were treated with additional forms of non-operative Hasan Kara, MD, Yalova, Turkey (n)
therapy (control group). All ESWT procedures were performed Saime Ramadan, MD (n)
using either a local anesthesia field block (LA subgroup, 12 Tanil Esemenli, MD, Istanbul, Turkey (n)
patients) or an anesthesia other than local (NLA subgroup, 23 Abstract: Exposure to air is a common occurrence during the
patients). Evaluation was by change in visual analog score (VAS) surgical repair of the tendons. Irrigation is a consideration that
and by determination of the Roles and Maudsley score. One prevents the deleterious effects of dehydration. In the current
month, three months, and twelve months post treatment, the study, the cellular and biomechanical effects of dehydration and
mean VAS for the control and ESWT groups were 8.2 and 4.2 ( irrigation on the healing of the Achilles tendon was investigated.
p<.001), 7.2 and 2.9 ( p<.001), and 7.0 and 2.8 ( p<.001) respec- Achilles tendons of 45 rats were tenotomized. In the control
tively. ). Chi square analysis revealed that the number of patients group (group I),the tendon was sutured with a Kessler tech-
with excellent or good Roles and Maudsley scores (i.e. successful nique. In the others, the skin over the tendon was retracted to
results) twelve months post treatment was statistically greater in allow the tendon direct exposure to room air. Irrigation of the
the ESWT group compared to the control group (p>0.0002). Achilles tendon was performed in one of the exposed groups
ANOVA testing at twelve months post treatment revealed that (Group II), while irrigation was not done in the other group
the mean improvement in VAS score for the LA subgroup was (Group III). After 60 minutes of exposure to air, tendons of the
significantly less than the corresponding gain in the NLA both groups were sutured the same as the control group. Rats
subgroup (F = 16.77 verses F = 53.95, p < .001). The percentage were sacrificed at postoperative day 28. Tendons were dissected,
of patients with excellent or good Roles and Maudsley scores did and histological and biomechanical evaluations were
not differ among the LA and and NLA subgroup. Eighty-three performed. Histological evaluation revealed intense fibrosis
percent of the ESWT patients were assigned an excellent or good formation with adhesion of the tendon to the surrounding

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

result twelve months post treatment. ESWT is an effective treat- tissues in the air exposed groups regardless of irrigation. Tensile
ment for chronic insertional Achilles tendinopathy. Local field strength of the repair was higher in the air exposed groups than
block anesthesia may decrease the effectiveness of this procedure the control group in biomechanical evaluation. Aridity of the
as determined by change in VAS score. Achilles tendon is a factor that decreases the quality of healing
by increasing fibrosis formation. Irrigation did not counteract
PAPER NO. 179 the negative effects of air exposure. Air exposure had no adverse
Faster Rehabilitation for Achilles Tendon Ruptures effect on the tensile strength of the healing tendon and a relation
Matthew L Costa, FRCS, Coventry, United Kingdom (n) between the amount of fibrosis formation and the tensile
Lee Shepstone, PhD (n) strength might be considered.
Rachel Chester, MSc (n)
Simon Thomas Donell, MD, Norwich, United Kingdom (n)
Fred Robinson, FRCS (n) POSTERS
Abstract: Achilles tendon rupture is a serious and disabling
condition associated with prolonged periods off work and away
from sporting activity. We performed two randomised POSTER NO. P206
controlled trials to assess the potential benefits of immediate Subtalar Arthrodesis Using Interpositional Fresh-
weight-bearing mobilisation for Achilles tendon ruptures. The Frozen Structural Allograft
treatment group were mobilised fully weight-bearing in an off-
Mark E Easley, MD, Durham, NC (n)
the-shelf orthosis. The control group were treated in traditional
serial equinus plaster casts. The first trial provides strong James R Santangelo, MD, Fayetteville, NC (n)
evidence of improved functional outcome for patients mobilised David William Wang, MD, Durham, NC (n)
fully weight-bearing after operative repair of their Achilles Abstract: Subtalar bone-block distraction arthrodesis using auto-
tendon rupture. The treatment group had a faster return to graft carries a donor site morbidity risk. The outcome of allograft
normal walking (p = 0.027) and normal stair climbing (p = use for this procedure has not been well established. This
0.023) than the control group. The second trial provides only prospective study determined the outcome of subtalar
weak evidence of a functional benefit from immediate weight- arthrodesis using interpositional fresh-frozen structural allograft.
bearing mobilisation for non-operatively managed Achilles Twenty patients (21 feet, mean age 49 years) underwent subtalar
tendon ruptures The only significant difference between the arthrodesis with interpositional fresh-frozen femoral head struc-
groups was an improved self-assessment of functional activities tural allograft by a single surgeon. Indications included subtalar
during the early stages of rehabilitation (p= 0.05). However, the arthrosis, heel height loss, and anterior ankle impingement.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
497
PPSE 07:Layout 1 1/12/07 1:41 PM Page 498

Clinical outcome was assessed using AOFAS hindfoot scoring POSTER NO. P208
and weight-bearing radiographic analysis by an independent Triple Arthrodesis Using a Trabecular Metal
observer. Time to union/healing was determined by radi-
ographic evidence of bridging trabeculation and graft revascu- Implant: A Canine Study
larization. Mean follow-up was 24 months (range 12-62). John S Reach, MD, Durham, NC (a – Zimmer/Implex)
Union was achieved in 19/21 patients at a mean of 15.5 weeks Julie E Adams, MD, Rochester, MN (a – Zimmer/Implex)
(11-19). Mean AOFAS hindfoot score improved from 21 to 70 Mark E Zobitz, MS, Rochester, MN (n)
points. Radiographic analysis indicated significant (p < 0.05) Kai-Nan An, PhD, Rochester, MN (n)
improvements in all measurements. Mean calcaneal pitch, talo- David G Lewallen, MD, Rochester, MN (a – Zimmer/Implex)
calcaneal angle, and talar-first metatarsal angles improved from
Scott P Steinmann, MD, Rochester, MN
19, 21, and 13 degrees to 21, 34, and 7 degrees, respectively.
Mean talocalcaneal height increased from 69 mm to 74 mm. (a – Zimmer/Implex)
Complications included nonunion (2), varus malalignment (1), Abstract: Triple arthrodesis is a common and successful foot and
persistent subfibular impingement (1), sural neuralgia (1), and ankle surgery. Existing techniques are technically demanding,
prominent hardware (2). These findings support recent reports necessitate long recovery periods, and often require autogenous
of favorable outcomes for subtalar arthrodesis using interposi- bone grafting. We hypothesized that bone ingrowth through a
tional structural allograft. Our clinical and radiographic results porous metal implant would provide secure fixation for rapid
show that restoration of hindfoot function and dimensions with return to weight bearing, restoration and maintenance of foot
structural allograft produces results comparable to those height, and obviation of autogenous bone grafting morbidity. In
reported for the same procedure using autograft. twenty-four skeletally mature mongrel canine forepaws, a 89 per
cent porous tantalum implant was press-fit between the
POSTER NO. P207 denuded radial carpal, ulnar carpal, and distal carpal IV bones
(homologues of the talus, navicular and cuboid). Immediate
Ankle Fusion in Hemophilia postoperative weight bearing was allowed. Animals were sacri-
Mauricio Silva, MD, Los Angeles, CA (n) ficed at 4, 8 and 12-week intervals. Biomechanic, radiographic,
Yi-Jen Fong, BA, Los Angeles, CA (n) and quantitative histomorphometric data was collected.
James V Luck Jr, MD, Los Angeles, CA (n) Biomechanical testing showed a significant increase in strength
Abstract: Pain and disability due to ankle arthropathy is of fusion over time (an indication of bone-metal healing).
common in hemophilic patients From 1971 to 2004, 39 ankle Radiographs demonstrated maintenance of foot height.
fusions in 30 hemophiliacs were performed at the author’s insti- Histology revealed bony ingrowth at 4-weeks. Quantitative
tution, and followed for at least 6 months or until fusion. histomorphometry showed increased bone-to-implant contact
Clinical materials were reviewed retrospectively. 85 percent of area and area occupied by bone. This study presents a novel use
cases were performed in severe hemophiliacs. HIV was present in of a porous metal implant as an adjuvant to tarsal bone fusion.
70 percent of the cases. The mean age at surgery was 40 years Future study will be needed to determine indications for human
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

(18-60). The primary procedure was an isolated tibio-talar (TT) foot and ankle application.
fusion in 24 cases, a TT and sub-talar (ST) fusion in 11cases, and
an isolated ST fusion in 4 cases The mean follow-up was 52 POSTER NO. P209
months. No intra-operative or immediate post-operative Components of the Wilson Osteotomy Effective on
complications were observed. There were two infections (5
percent): One pin-site infection in a patient in whom a Charnley
Hallux Valgus Repair
compression device was used, and one tibial osteomyelitis that Yakup Yildirim, MD, Philadelphia, PA (n)
developed 10 years after the ankle fusion. Non-unions (NU) Baransel Saygi, MD, Istanbul, Turkey (n)
were observed in 20 percent of TT fusions and in 27 percent of Nuri Aydin, MD (n)
ST fusions. Most were non-painful, and did not required addi- Cengiz Cabukoglu, MD, Istanbul, Turkey (n)
tional surgery. Before 1995, the incidence of NU in isolated TT Severino R Bautista, Jr MD, Philadelphia, PA (n)
fusions was 27 percent, as compared to 11 percent after 1995 Abstract: Wilson oblique osteotomy is a technically simple and
when newer techniques were used (p=0.2). The incidence of ST satisfactory treatment for HV deformity. First metatarsal short-
NU decreased after 1995 (50.0 percent vs. 22.2 percent), when ening is the main disadvantage of the technique. The purpose of
T-plates were introduced as part of the surgical technique. A the study was to evaluate the effect of osteotomy angle,
second surgery was required in 6 cases (15.4%): 3 screw osteotomy location and amount of lateralization on the correc-
removals due to pain, one talo-navicular fusion, one ST fusion, tion of HV and their relation to the first metatarsal shortening.
and one below-the-knee amputation due to osteomyelitis. Ankle Wilson osteotomy was performed on 46 feet in 32 patients. The
fusion is an excellent alternative for end-stage hemophilic radiographs of the patients were evaluated according to the
arthropathy. However, the incidence of NU is high, especially for osteotomy distance to the first MTP joint, osteotomy angle and
sub-talar fusions. Improvements in surgical techniques may the amount of lateralization of the first metatarsal head. The
reduce this incidence effect of variables on the correction of HV deformity was inves-
tigated. The correlation between the variables and the first
metatarsal shortening was also evaluated. The average preopera-
tive and postoperative HV angles were 28.9 degrees and 8.9
degrees respectively.The average osteotomy angle was 22.5
degrees and the average distance of the osteotomy to the 1st MTP
joint was 20.2 mm. The mean lateral shifting of the metatarsal
head was 8.6 mm. The average metatarsal shortening was 5.1
mm. Among the investigated variables, lateralization of the
metatarsal head was found to be the most significant inde-

498 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 499

pendent factor for HV correction (p<0.01). A significant correla- POSTER NO. P211
tion was present between the metatarsal shortening and the Biomechanical Analysis of a Tissue Augment in
osteotomy angle. The main aim in Wilson osteotomy should be
lateralization of the metatarsal head for correction of the HV Achilles Tendon Repair
deformity. An average of 22.5 degrees osteotomy angle was suffi- Jarred Sakakeeny, MS, Ashland, MA
cient for a satisfactory correction. High angled osteotomy (45 (a – Stryker Howmedica, Tufts University)
degrees as in original description) is a main cause of metatarsal Suzanne L Miller, MD, Newton, MA
shortening. (a – Stryker Howmedica)
Ken James, Ph.D., Boston, MA
POSTER NO. P210
(a – Stryker Howmedica, e – TEI Biosciences Inc.)
Patient-Specific Modeling of Increased Contact Abstract: Processed collagen grafts are increasingly being used in
Stress Exposure after Intra-Articular Pilon Fractures orthopedic surgery to reinforce repairs of torn tendons, yet little
John Lawrence Marsh, MD, Iowa City, IA (n) is known about the biomechanical changes. The purpose of this
Jane Goldsworthy, BSE (n) study was to measure the immediate physicomechanical differ-
Don Anderson, PhD (n) ences between traditional Achilles tendons repair and two
augment techniques. Identical ruptures were created in 18 sheep
Thad Thomas, BSE (n)
Achilles tendons 3 cm above the tendinous insertion and were
Valerie Muehling, MS, Iowa City, IA (n) repaired using one of the following three techniques
Thomas D Brown, PH D, Iowa City, IA (n) (n=6/group): 1) Non-augmented repair using a running locking
Abstract: Articular surface incongruities resulting from intra- stitch; 2) Augmented repair using a 1x4 cm strip of TissueMend
articular fractures of the ankle lead to abnormal tibio-talar (Stryker Orthopaedics, Mahwah, NJ); 3) Augmented repair using
contact stress distribution and are a critical determinant of post- TissueMend wrapped circumferentially around the tendon.
traumatic osteoarthritis (OA). Unfortunately, it has not been Maximum load to failure, load to 2 mm gap formation, stiffness,
possible to measure increased contact stress produced by fracture and mode of failure were compared. There was a significant
incongruity in patients. This study reports the first use of a finite difference in load to failure and load to 2 mm gap formation
element (FE) modeling approach to measure the contact stress between all groups (p<.05). Average loads at failure for groups 1,
distribution in ankles with tibial plafond fractures as compared 2, and 3 were 125.5 N, 185.8 N, and 259.3 N respectively.
to the contralateral normal ankle. CT datasets obtained of the Average load to 2 mm gap formation for each group were 108.8
noninjured and injured ankles, after reduction and fracture fixa- N, 181 N, 241 N respectively. There was no significant difference
tion are segmented to yield bone surfaces. Data Manager, a in stiffness between groups. The TissueMend graft distributed
medical data visualization program, is used to bring the surfaces load and enhanced suture retention to strengthen Achilles
into weight-bearing apposition (Figure 1). A commercial tendon repairs as much as 107% (wrap technique). Strength
meshing program is used to construct a FE mesh. The FE model increase was accomplished without increasing construct stiff-
is then subjected to a gait simulation, in which the axially loaded

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

ness, addressing the concern that stress shielding could inhibit
tibia is rotated about the flexion/extension axis, while the talus tendon healing. The clinical benefits of collagen augments
is free to rotate as dictated by the articulation with the tibia. remains to be determined.
Chronic contact stress exposures are calculated for each patient.
Computed contact stress exposures for intact ankles were contin- POSTER NO. P212
uous and relatively uniform, and located on a consistent region Computed Tomographic Evaluation of the
of the tibial articular surface. Fractured ankles exhibited higher
magnitude, less consistently located, and more focal contact Recurrent Peroneal Tendon Dislocation
stress exposures (Figure 2). The average peak computed contact Noguchi Hideo, MD, Gyoda-Shi, Japan (n)
stress exposure was 11.1+/-1.2 MPa for the intact ankles and Ishii Yoshinori, MD, Gyoda, Japan (n)
13.9+/-1.8 MPa for the fractured ankles. Fractured ankles had a Matsuda Yoshikazu, MD, Gyoda, Japan (n)
larger percentage of contact area with higher magnitudes of Hasegawa Atsushi, MD, Maebashi Gunma, Japan (n)
contact stress exposure and a smaller percentage exposed to Kenji Takagishi, Prof., Maebashi, Japan (n)
lower stresses. Patient specific FE models developed from CT
Yasuyuki Nakajima, MD, Saitama, Japan (n)
datasets demonstrated different patterns and magnitudes of
contact loading in ankle fractures of the tibial articular surface Mitsuhiro Takeda, MD, Gunma, Japan (n)
compared to the contralateral normal ankles. This is the first Abstract: The purpose of this report is to evaluate the shape of
time the mechanical effect of intraarticular fracture displace- the peroneal groove, and the area of soft tissue occupying the
ments has been measured. Further work will assess the effect of peroneal tendon sheath by computed tomography. Computed
the measured contact loading abnormalities on the articular tomographic evaluations were obtained for 38 ankles that had
cartilage and on clinical outcome. This technique has the poten- been diagnosed with recurrent peroneal tendon dislocation
tial to increase our understanding of the mechanical effects of (dislocation group) and 38 ankles without any dislocation
articular surface step-off’s and may have clinical utility in the (control group). The fibular groove angle (FGA) and the soft
future. tissue ratio (STR) were measured at the level of the ankle joint.
FGA was defined as the angle between the bisecting line of the
talar body and the line of the posterior wall of the fibula. STR
was defined as the area of soft tissue occupying the peroneal
tendon sheath divided by the area of the fibula. The mean FGA
was 37.5±8.5 degrees in the dislocation group and 34.1±9.0
degrees in the control group. There was no significant difference
between these values. The mean STR was 0.717 in the dislocation
group and 0.320 in the control group. The STR was significantly

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
499
PPSE 07:Layout 1 1/12/07 1:41 PM Page 500

different between groups (p=0.04). Some reports have described POSTER NO. P214
hypoplasia of the fibular groove as the primary cause of peroneal Prevention of Immobilization Related Muscular
tendon dislocation. However, our results demonstrate that
hypoplasia of the groove is not altered in cases of peroneal Atrophy Using the Myospare Device
tendon dislocation. Since the area of soft tissue occupying the Efraim Leibner, MD, Jerusalem, Israel (b – StimuHeal)
peroneal tendon sheath was larger for the dislocation group Miguel Hernandez, MD, Jerusalem, Israel (b – StimuHeal)
compared with the control group, we believe that these results Eli London, DPM, Jerusalem, Israel (n)
can serve as an index for determining the most suitable proce- Ofer Elishoov, MD, Jerusalem, Israel (n)
dure. Mira Shiloach, MSc, Evanston, IL (n)
POSTER NO. P213 Meir Liebergall, MD, Jerusalem, Israel (a – StimuHeal)
Abstract: Musculoskeletal injuries reduce limb activity,
Independent Retrospective Review of Surgical promoting muscular atrophy, and slowing return to function.
Decompression for Diabetic Neuropathy Atrophy prevention using electrical stimulation has been
Suyoung Bae, MD, Baltimore, MD (n) attempted after knee immobilization, but not after ankle
Lew C Schon, MD, Baltimore, MD injuries. The Myospare percutaneous stimulator has been devel-
(a – EBI Synthes KMI, a, e – Depuy, a, d, e – Nexa, oped to prevent immobilization related atrophy. We undertook
a pilot study to assess feasibility, safety, and efficacy of electrical
c – Aircast(DJ) Arthrex Zimmer Darco)
stimulation under a cast after ankle fractures. Between May and
Kent R Biddinger, MD, Midland, MI (n) December 2004, 24 adult patients with closed ankle fractures
Abstract: It has been reported that diabetic neuropathic pain and requiring surgery, participated in a study assessing a new device
numbness can be improved by decompression surgery for the for reducing immobilization related atrophy. Patients were
lower extremity peripheral nerves. We present the results from randomized to treatment and control groups. All patients under-
retrospective and independent objective review for this surgical went ORIF using standard technique. Postoperatively, a short
procedure using diversified standardized assessment tools. walking cast was applied, with weight bearing as tolerated. The
Thirty three consecutive patients (14 unilateral and 19 bilateral) device was applied in the treatment group for 6 weeks. Patients
had peripheral nerve release surgeries of common peroneal were examined at 2, 6 and 12 weeks. Evaluation included calf
nerves, deep peroneal nerves and tibial nerves were reviewed by and ankle circumference, ankle motion, and function. Pain was
a disinterested investigator retrospectively and independently of assessed using a visual analog score. Subjects were queried for
the surgeon. The patients were assessed with clinical protocols at adverse effects and comments about device use. Analysis was
a mean of 28.3 months postoperatively and medical records performed using independent samples t-test, chi-square and
were reviewed. SF-36v2TM health survey forms, Foot Function repeated measures analysis. All patients tolerated the stimulator
Index (FFI), Neuropathic Pain Scale (NPS), Leeds Assessment of well. No adverse effects were encountered. There were significant
Neurologic Symptom and Signs (LANSS) scale, self-post opera- improvements in function and pain reduction. A trend toward
tive symptom progress scale, and simple neurologic tests for the
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

improvement in calf diameter, dorsiflexion and plantar flexion

evaluation of senasation were used for clinical assessment. was apparent, but not statistically significant. Use of the
Patient’s satisfactions were good to excellent in 24 cases (46%), Myospare device under a cast in patients after ankle ORIF is
fair in 18 cases (35%), no change or aggravation in 10 cases feasible and safe. In this pilot study, a trend toward enhanced
(19%) in terms of pain. In terms of sensory improvement, the recovery was apparent.
results were good to excellent in 20 cases (38%), fair in 18 cases
(35%) and poor in 14 cases (27%). There is no significant differ- POSTER NO. P215
ence in sensory tests results between groups except 2 point
discrimination test. In 13 cases, pain was aggravated after one
Minimally Invasive Technique for Harvesting Flexor
year. The SF-36v2TM forms provided that the ‘vitality score’ was Digitorum Longus Tendon in Foot: A Cadaver Study
significantly higher in the group that had excellent results and Vinod Kumar Panchbhavi, MD, Galveston, TX (n)
the ‘role emotional score’ was significantly lower in the group Jinping Yang, MD, Galveston, TX (n)
that had poor results. Intensity score among the NPS had a posi- Abstract: Flexor digitorum longus (FDL) tendon transfer to
tive correlation with clinical result. In the group with poor navicular is an established foot reconstructive procedure. The
results, the scores from the questionnaire about ‘how hot’ and current technique to harvest the FDL tendon however requires
‘how sensitive’ were low. The overall results were not as favorable extensive, deep and difficult dissection in the midfoot in vicinity
as previous publications. This retrospective review shows that of blood vessels and nerves.A cadaver study was performed to
intense pain and hypersensitivity from the diabetic neuropathy determine feasibility and safety of a new minimally invasive
can be a good indication for the nerve release surgery. Despite technique. A malleable probe was introduced within the FDL
reports in the literature of improved sensation, however the tendon sheath and passed gently from hindfoot into the
results of this study were equivocal. NPS can be a valuable tool midfoot where it is palpated to guide exposure and harvest of the
to identify good prognostic factors for surgical decompression tendon through a small vertical incision in the midfoot. This
for diabetic neuropathy. new technique was tested for its efficacy and safety and to docu-
ment relevant surgical anatomy in 16 feet. The surface marking
for the division of FDL tendon on the sole of the foot was found
to be at a midpoint between the posterior edge of the heel and
the proximal flexor crease at the base of 2nd toe and on average
3.7 cm medial to lateral border of the foot. On average the lateral
plantar nerve was 0.86 cm and the medial plantar nerve was 0.43
cm away from the FDL division. The FDL tendon harvested
measured on average 9.04 cm long to the cut end from a point
on the tendon at the level of the tip of medial malleolus. No

500 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 501

damage to the adjacent structures was identified. Surface harvested, radiographed, and tested for stiffness and torque to
anatomy can be used to locate point of division of the FDL failure. Histological sections were then obtained. Fusion rate was
tendon in the midfoot. This surface and relevant surgical 100 percent with irrigation, 75 percent without (p 0.45).
anatomy useful for this technique has not been described previ- Mechanical testing mean values increased by 14.4 percent and
ously. It is possible to harvest FDL through a minimally invasive 7.7 percent for torque to failure and stiffness, respectively with
technique. irrigant. Histology showed less mature bone formation in non-
irrigated specimens. Given the results of our study, we recom-
POSTER NO. P216 mend that chilled irrigant should be applied continuously
Open Reduction and Internal Fixation of the during arthrodesis procedures when high speed burring is
performed with the goal of limiting thermal induced alterations
Symptomatic Type II Accessory Navicular in healing and increasing fusion potential.
Jonathan Saluta, MD, Los Angeles, CA (n)
Mark E Easley, MD, Durham, NC (n) POSTER NO. P218
Abstract: This is a prospective study of ORIF of the symptomatic A New Technique for the Surgical Management of
type II accessory navicular. Seventeen consecutive patients
(average age 25 years (range, 11-59 years) with symptomatic type
Advanced Hallux Rigidus with or without Deformity
II accessory naviculars failing nonoperative measures were Thomas P SanGiovanni, MD, Coral Gables, FL (n)
managed by a single surgeon using a prospectively assigned Angie L Botto-van Bemden, PhD, Coral Gables, FL (*)
algorithm: accessory naviculars of adequate size to support screw Abstract: The HemiCAPTM Contoured Articular Prosthetic
fixation underwent ORIF (10), and accessory naviculars of directly addresses the pathology of the 1st metatarsal head and
smaller size underwent excision (7). The determination of may be combined with other procedures, if necessary, to correct
adequate size to support screw fixation was made intraopera- concomitant pathologies. In 2005, twenty-four cases (20
tively. Outcome was assessed with the AOFAS midfoot clinical patients - 4 were bilaterals) underwent first metatarsal head
rating system (preop and at followup), weightbearing foot radi- resurfacing by the senior author. Concomitant procedures
ographs and an external oblique view (preop and at followup). included the following: plantar plate release/Moberg proximal
Evaluation was by independent observer. For the ORIF group phalangeal closing wedge osteotomy to improve dorsiflexion
(average follow-up of 31 months (range 11-71)), the average when required, biplanar proximal phalangeal closing wedge
AOFAS score improved from 49 (range 0-62) to 89 (range 69- osteotomy (Moberg-Akin) to address correction of hallux valgus
100) points. Radiographic analysis suggested an 80% (8/10) deformity, split EHL tendon transfer to address hallux varus
union rate, with only one of these two patients (10%) being deformity and 1st interphalangeal joint arthrodesis to address
symptomatic. A single patient (10%) had painful hardware, but combined IP and MTP arthrosis. The average follow-up was 12
was asymptomatic after screw removal. For patients treated with months (range; 10-12). Average postoperative scores for the
excision (average followup of 48 months (range 24-68)), the AOFAS (from 54.7 to 70), VAS (from 6.4 to 3.5), and dorsi-
average AOFAS score improved from 45 (range 26-70) to 78 flexion (from 20.2 to 51) demonstrated significant improvement

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

(range 26-93) points. Three of seven feet (43%) treated with when compared to preoperative scores. The HemiCAPTM partial
excision had persistent midfoot pain and progressive loss of the resurfacing prosthesis appears to be a reliable alternative for
longitudinal arch. This study suggests that, albeit controversial, patients diagnosed with advanced hallux rigidus. Importantly, it
ORIF in lieu of excision of the symptomatic type II accessory is a device for arthritis; not a device for motion. Dorsiflexion
navicular may have merit. motion may further be improved through concomitant proce-
dures; for example, a soft tissue release or bony procedure
POSTER NO. P217 followed by aggressive early motion program.
The Effect of Continuous Irrigation During Burring
POSTER NO. P219
on Fusion Strength in a Rabbit Arthrodesis Model
The Bridle Procedure to Restore Dorsiflexion
Steven L Haddad, MD, Glenview, IL (a, e – DePuy)
Cary Templin, MD, La Jolla, CA (n) Paralysis of the Foot
Bruce Stewart, MD, Chicago, IL (n) Raoul P Rodriguez, MD, New Orleans, LA (n)
Navjot Kohli, MD, Chicago, IL (n) Abstract: The Bridle procedure is a posterior tibial tendon
Yupeng Ren, MS (n) transfer through the interosseus membrane with insertion of the
posterior tibial tendon into the second cuneiform bone with
Li-Qun Zhang, PhD, Chicago, IL (n)
anastomosis to the anterior tibial and peroneus longus resulting
Abstract: High-speed rotary burrs used in the preparation of
in a balanced foot. This procedure is performed for loss of dorsi-
articular surfaces for arthrodesis can cause heat generation, and
flexion of the foot. This is a retrospective review of 27 patients
this may impede healing. Irrigation during burring has been
with 30 feet (3 bilateral) for multiple diagnoses, the most
shown to aid the early healing potential or burred bone surfaces,
common being peripheral nerve injury. Follow-up is from 16
and may result in a stronger fusion if utilized during arthrodesis
months to 26 years. The mean was 9.8 years. Twenty-four
procedures. This benefit, however, has not been substantiated in
patients with 27 feet (3 bilateral) with a muscle grade of 4 or 5
an in vivo arthrodesis model. We hypothesize that 6 degree C
before surgery experienced satisfactory results, ambulating free
irrigant as opposed to no irrigant during joint surface prepara-
of external support. In 3 patients with a muscle grade of 3, the
tion with a high-speed burr will result in a stronger fusion or
tendon transfer functions as a tenodesis, two required ankle foot
increased fusion rate in rabbit elbow specimens at a six week
orthosis and the third had a tibio talo calcaneal fusion. Twenty-
end-point. A rabbit elbow arthrodesis model was developed and
six of the 27 patients are moderately or very satisfied with this
utilized. The joint was prepared and contoured with a high
procedure. The patient that required a tibio talo calcaneal fusion
speed cutting burr and fixed in compression. The joints were
was not satisfied. Patients with a Watkins posterior tibial tendon
either irrigated with 6 degree C saline or not irrigated during
transfer through the interosseus membrane to the dorsum of the
preparation. A total of 16 animals were tested. Specimens were

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
501
PPSE 07:Layout 1 1/12/07 1:41 PM Page 502

foot usually require bone stabilization due to the possible varus graphics such as age gender and ethnicity were
or valgus imbalance which is avoided by the modified Bridle collected.Statistical analysis of the results was performed using
procedure. There was a direct correlation in our patients on the the Microsoft Excel Data Analysis Software and student t-test. A
satisfactory restoration of dorsiflexion function with the muscle total of 172 feet were studied. There were 16 Afro-American men
grading of the posterior tibial muscle before surgery. (AAM), 13 Caucasian men (CM), 23 Afro-American women
(AAW) and 34 Caucasian women (CW) in the series. Hallux
POSTER NO. P220 valgus measurement: The average degree was 18.7 in AAM, 15.7
Sesamoid Position and Metatarsosesamoid Arthritis in AAW, 16.2 in CM and 15.9 in CW. 18.7. t- test revealed no
significant differences (p value = 0.927). Intermetatarsal meas-
Affects on Surgical Outcomes of Bunion Correction urement: average degree was 8.91 in AAM, 7.84 in AAW, 8.66 in
Kali Danielle Arnold, MD, Pittsburgh, PA (n) CM and 9.27 in CW. t-test revealed no significant differences (p
Stephen F Conti, MD, Pittsburgh, PA (n) value ‘ 0.732).Talo-first metatarsal angle: average degree was 5.48
Jorge Bustillo, MD, Hershey, PA (n) in AAM, 8.00 in AAW,4.05 in CM and 5.98 in CW. t-test revealed
Gary Wayne Stewart, MD, Mcdonough, GA (n) no significant difference (p value ‘ 0.098).Metatarsal span:
Chad Peterson, PA-C (n) average in centimeters was 9.75 in AAM, 8.68 in AAW, 9.51 in
Abstract: It has been our observation during surgical correction CM and 8.43 in CW. t-test revealed no significant difference (p
of bunion deformity that little arthritis exists in the MTP joint value ‘ 0.059).Calcaneal pitch: average degree was 15.8 in AAM,
irrespective of congruence of the joint or magnitude of HVA. 13.4 in AAW, 21.9 in CM and 20.5 in CW. t-test revealed the
However, there is significant arthritis observed in the metatar- following. For black and white men the p values were 0.004
sosesamoid (MTS) articulation which we believe is a major (right feet), 0.014 (left feet) and 0.0001 (both feet). The p values
factor affecting final surgical outcome. The purpose of this study in the female group were 0.00003 (right feet), 0.00001 (left feet)
is to evaluate the results of surgical correction of a congruent and 0.00000000132 (both feet). The t-test did find a major
bunion deformity using the distal chevron osteotomy (DCO) difference between the races with regards to the calcaneal pitch.
performed alone or in combination with a modified distal soft This study revealed a statistically significant difference in the
tissue procedure (DSTR). 96 patients that had DCO w/ DSTR calcaneal pitch angle measurements of the weight bearing foot
(41pts) or DCO alone (55pts) were retrospectively reviewed over between different races. There are no previous studies docu-
8 yrs. HVA, IMA, DMAA, congruency of 1st MTP joint, 1st MTP menting such a difference. Further studies are necessary to inves-
arthritis, sesamoid position, degree of MTS arthritis, ratio of tigate if these radiographically detectable morphologic
length of 1st and 2nd metatarsals, MTS arthritis and erosion of differences are associated with differences in incidences of foot
the crista were evaluated radiographically. A combined clinical problems between different races.
and radiographic criterion on a scale from 0-4 was used to grade
POSTER NO. P222
1st MTP arthritis. AOFAS scale of grade 0-3 was used to grade
tibial sesamoid position. Satterthwaite-Cochran was used for The “Kick-Off” Position: A New Sign for Early
statistical evaluation. The postoperative position of the Diagnosis of Complex Regional Pain Syndrome in
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

sesamoids in DCO/DSTR pts was significantly improved

compared to DCO pts with a p-value of 0.05. Postoperative
the Leg
average AOFAS forefoot scores were 84.6 DCO pts and 91.0 for Vinod Kumar Panchbhavi, MD, Galveston, TX (n)
DCO/DSTR pts. The average score for pts >50yrs 81.7 compared Saul Generoso Trevino, MD, Galveston, TX (n)
to pts < 50yrs with score of 92.2. The results of this study suggest Oscar Castro-Aragon, MD, Galveston, TX (n)
correction of sesamoid position may improve surgical results. Margaret Rowell, RN, Galveston, TX (n)
Jeannie Jo, DPM (n)
POSTER NO. P221 Abstract: Complex regional pain syndrome (CRPS) is a clinical
Radiographic Differences in the Morphology of the entity that develops after a precipitating injury. It involves
Weight Bearing Foot Between Different Races dysfunction of the sensory, autonomic, and motor systems and
frequently is missed on initial presentation. The purpose of this
Vinod Kumar Panchbhavi, MD, Galveston, TX (n)
report is to describe a simple clinical sign that can aid its diag-
Saul Generoso Trevino, MD, Galveston, TX (n) nosis. A retrospective review was conducted of 39 consecutive
Oscar Castro-Aragon, MD, Galveston, TX (n) patients with CRPS type I or II seen in the Foot and Ankle Clinic
Abstract: It was hypothesized that there will be a significant between Oct 2001 and May 2005. The diagnosis was based on
difference in the measurements obtained of the radiographic clinical findings. 26 patients had type I (67%) and 13 patients
parameters on weight bearing radiographs of the feet in between had type II (33%). The most common nerve involved in type II
patients belonging to different races. An IRB approval was was the superficial peroneal nerve. Each patient, while sitting on
obtained for this prospective study. A consecutive series of the exam table, held the affected extremity with the knee
patients over 17 years of age, who had weight bearing bilateral extended against gravity. When the leg was pushed back to a
foot radiographs in a standardized way were included in the relaxed and suspended position, eventually the patient involun-
study. Those patients who had fractures, past surgery, tarily resumed the extended position. This position in which the
neuropathy, deformity or amputations in the lower extremities patients held their legs was termed the kick-off’ position sign
were excluded.The method of measuring radiographic parame- (KOPS). Nine patients were seen at the foot and ankle clinic
ters on digital monitors using digital tools was standardized. The within six weeks of the initial inciting event and had an estab-
radiographic parameters measured were the hallux valgus angle, lished KOPS within three months from the time of injury. The
the intermetatarsal angle, the talo first metatarasal angle, the disappearance of this sign correlated with the subsidence of
calcaneal pitch and a new parameter termed the ‘metatarsal pain. Patients with CRPS have variable clinical presentations.
span’. The metatarsal span is the distance between the most The awareness of this simple observation in the right clinical
prominent points on heads of first and fifth metatarsals on a
weight bearing anteroposterior radiograph. Patient demo-

502 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 503

setting should raise the index of suspicion towards considering The prevalence of type A (77%) in Group N was significantly
CRPS in the differential diagnosis. The early treatment of this greater than that (3.3%) in Group HV (p<0.0001). The preva-
syndrome is associated with better outcome. lence of type R (78.3%) in Group HV was significantly greater
than that (3%) in Group N (p<0.0001). Conclusions: The most
POSTER NO. P223 frequent shape of the lateral edge of the first metatarsal in Group
Force- and Moment-Generating Capacity of Flexor HV was type R and not type A that was most common in Group
N. We concluded that there was a significant relationship
Digitorum Longus Following Tendon Transfer between a round shaped lateral edge of the first metatarsal head
Joe Hui, BS, Salt Lake City, UT (a – University of Utah) and hallux valgus deformity.
Nicholas Brown, PhD, Salt Lake City, UT
(a – University of Utah)
Timothy C Beals, MD, Salt Lake City, UT
(a – University of Utah)
SCIENTIFIC EXHIBIT
Abstract: The purpose of this research was to quantify the
maximal isometric forces and moments that FDL is capable of SCIENTIFIC EXHIBIT NO. SE42
producing following tendon transfer. It was hypothesized that in Complex Ankle Fusion with the Ilizarov/Taylor
comparison to the native state, the hindfoot moment arm, force
and moment produced by FDL would increase following tendon
Spatial Frame
transfer to either the medical cuneiform or navicular bones. In S Robert Rozbruch, MD, New York, NY
six cadaveric specimens, muscle moment arms for FDL and (a – Smith and Nephew)
posterior tibialis were determined using the tendon-excursion Austin Fragomen, MD, New York, NY
method (An et al., 1984). Moment arms were measured with (a – Smith and Nephew)
both muscles in their native state and with FDL transferred to Nazzar Tellisi, MD, New York, NY (n)
either the plantar aspect of the navicular or medial cuneiform Svetlana Ilizarova, MD, New York, NY
bones. PT remained intact and served as a control. The FDL
(a – Smith and Nephew)
hindfoot moment arm magnitude measured in cadaveric speci-
mens decreased by up to 40% when transferred from its native Patients with complex ankle pathology often require ankle
state. These differences were not significant (p=0.122) due to arthrodesis for improved function and pain relief. However,
variability within specimens. Due to decreased moment arm problems of poor bony architecture, talar osteonecrosis, bone
magnitudes and no change in muscle force, the transferred FDL loss, osteomyelitis, joint contracture, and deformity make
produced lower inversion moments about the hindfoot attempts at ankle fusion a limb salvage undertaking for most of
compared with its native condition for neutral to everted these patients. The Ilizarov / Taylor spatial external fixator offers
subtalar joint positions. Transfer of the FDL tendon to the navic- an excellent alternative to standard fusion techniques. This
ular or medial cuneiform did not increase the capacity of the frame provides the versatility to deal with bone loss and infec-

PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

FDL muscle to invert (or resist eversion of) the hindfoot. In tion. Ankle arthrodesis with simultaneous tibial lengthening is
contrast, the transferred FDL tended to be less effective in this an effective way to reconstruct bone loss around the ankle. The
role suggesting little functional advantage is gained through its Taylor Spatial Frame (TSF) is an evolution of the classic Ilizarov
transfer to these sites. frame. It utilizes a computer program, which helps calculate a
schedule for gradual strut and frame adjustment to simultane-
POSTER NO. ORS 3 ously correct multiple aspects of deformity around a virtual
hinge without the need for complicated frame modification. In
The Shape of the Lateral Edge of the First Metatarsal this exhibit, we will present our clinical experience, surgical plan-
Head: Comparison of Normal and Hallux Valgus Feet ning, the deformity correction software, a video surgical demon-
Ryuzo Okuda, MD, Osaka Medical College, Japan (n) stration, and a computer animation. We retrospectively reviewed
Mitsuo Kinoshita, MD, Osaka Medical College, Japan (n) 52 consecutive patients who underwent ankle arthrodesis from
Toshito Yasuda, MD, Osaka Medical College, Japan (n) an IRB approved prospective database. Twenty-two patients had
ankle joint bone loss with an average 2.8cm (range: 1 to 8cm).
Tsuyoshi Jotoku, MD, Osaka Medical College, Japan (n)
Simultaneous or staged proximal tibial osteoplasty was
Naoshi Kitano, MD, Osaka Medical College, Japan (n) performed in nine cases. Average preoperative bone loss for this
Hiroyuki Shima, MD, Osaka Medical College, Japan (n) group was 4.2cm (range: 1.4 to 8cm) which increased with bony
Introduction: The purpose of this study was to analyze differ- resection at surgery. Average length obtained was 5.2cm (range:
ences in the shape of the lateral edge of the first metatarsal head 2 to 15cm). Average time in frame was six months (range: 4 to
between normal feet and hallux valgus feet. Methods: 23months). Eighty percent (31/39 patients) fusion rate was
Dorsoplantar weightbearing radiographs were reviewed in 60 achieved on the first attempt. Ninety percent fusion rate was
normal feet of adult females (Group N) and in 60 hallux valgus achieved on the second attempt (35/39) Half of those who
feet of adult females (Group HV), which were treated with a failed the first attempt united on the second attempt (4/8
proximal metatarsal osteotomy. The hallux valgus and inter- patients). One failed to unite after the second attempt and had
metatarsal angles were measured and the shape of the lateral a painless stiff nonunion. Two patients elected transtibial ampu-
edge, which was consisted of the articular and the lateral surfaces tation rather than undergo a second fusion attempt. One had a
of the first metatarsal head, was investigated. The shapes of the painless stiff nonunion after the first attempt and declined a
lateral edge were classified into three including round (type R), second attempt. In addition to the two patients who elected
angular (type A), and intermediate (type I) types according to amputation, one other patient underwent amputation for severe
our classification system. Results: The mean hallux valgus angle skin necrosis and osteomyelitis. Tibio-calcaneal fusion rate was
in Group N and HV were 11.5°(range, 3-19) and 39.2° (range, 70%. Preoperative infection was eradicated in all cases. Average
26-60), respectively. The mean intermetatarsal angle in Group N leg length discrepancy after treatment was 1.4cm. Smoking was
and HV were 9.8° (range, 4-15) and 18.1° (10-28), respectively.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
503
PPSE 07:Layout 1 1/12/07 1:41 PM Page 504

associated with a 62% failure rate (p=0.004) and a 25% ampu- SCIENTIFIC EXHIBIT NO. SE44
tation rate (p=0.00005). The ability to perform acute or gradual Correction of Hallux Valgus Using Lateral Soft
compression of the fusion site and deformity correction, simul-
taneous limb lengthening, and eradication of deep infection Tissue Release Through Medial Incision
make the Ilizarov method a powerful means of achieving ankle Prof Woo Chun Lee, Seoul, Republic of Korea (n)
arthrodesis in the presence of complex pathology. The Ilizarov Yu-Mi Kim, MD, Seoul, Republic of Korea (n)
/Taylor spatial frame provides the stability and adjustability We performed lateral soft tissue procedure through medial inci-
needed to meet the demands of these difficult fusions. The sion , but we did not release through the joint, we arrived at the
ability to maintain compression is a great strength. first web space by elevating dorsal flap over the first metatarsal
head and neck area. The purpose of this study was to review our
SCIENTIFIC EXHIBIT NO. SE43 experiences with hallux valgus deformity treated using lateral
How to Treat Severe Post-traumatic Arthritis of the soft tissue release and proximal chevron osteotomy through
Ankle Joint medial one incision. The charts and radiographs of 37 consecu-
tive patients with 45 hallux valgus who were operated on
Sandro Giannini, MD, Bologna, Italy (n) between August 2003 and May 2004 were reviewed. Ten feet of
Roberto Buda, Bologna, Italy (n) eight patients lacked adequate follow-up and they were
Cesare Faldini, MD, Bologna, Italy (n) excluded. The results of our operative procedures for the
Francesca Vannini, MD, Bologna, Italy (n) remaining 35 feet of 29 patients were investigated. The AOFAS
Matteo Romagnoli, MD, Bologna, Italy (n) score improved from an average of 54.8 preoperatively to 93.3
Gian Luca Grandi, MD, Bologna, Italy (n) postoperatively. Twenty-three patients stated that they would
Roberto Bevoni, MD, Bologna, Italy (n) undergo the same procedure again without reservations. The
INTRODUCTION: The aim of this scientific exhibit is to present hallux valgus angle improved an average of 27.8 degrees from a
guidelines for treatment of severe post-traumatic ankle arthritis preoperative average of 35.8 degrees to a postoperative average
(SPAA). MATERIAL AND METHODS: 190 SPAA grade II-III Van of 8.0 degrees. The intermetatarsal angle improved from a
Dijk classification, age ranged 17 to 60 were included. Sixty-two preoperative average of 16.8 degrees to a postoperative average
SPAA grade II were treated: 50 SPAA with ankle malunion by of 5.0 degrees. There were three cases of marginal necrosis which
distal tibial osteotomies; 12 SPAA without misalignment, by had healed without any further surgery. This study suggests that
arthroscopic toilette and arthrodiatasis for 4 weeks with external we could release lateral soft tissue by approaching the first web
fixator. One hundred twenty-eight SPAA grade III were treated: space dorsal to the first metatarsal after elevating skin and subcu-
58 cases any age with adequate midtarsal ROM or ankle taneous flap and satisfactory correction of hallux valgus defor-
anatomy disruption: fusion. Eighteen cases <50 years with ankle mity is obtained by proximally apexed proximal chevron
anatomy preserved: fresh bipolar osteochondral shell allograft. osteotomy.
Fifty-two cases >50 years with ankle anatomy preserved, low
functional demand or reduced midtarsal ROM, total ankle
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

replacement. All patients were checked at a mean follow-up of 5

years. RESULTS: Fused and saved ankle joints had 108 excellent
results, 57 good and 13 fair. Twelve poor results needed reoper-
ation. The 58 cases treated by fusion presented preoperative
AOFAS score 28.8±11 while postoperatively it was 77.5±8
(p<0.05). The 132 saved ankle joints presented preoperative
AOFAS score 32.5±12 while postoperatively it was 82.4±11
(p<0.05). Adequate ankle ROM was restored in 98 patients. X ray
analysis showed progression of arthritis in 62 cases. DISCUS-
SION AND CONCLUSION: Surgical strategy in SPAA should be
decided depending on radiographic classification, ankle align-
ment, the amount of disruption of the normal anatomy, activity
level and age of the patient. Following the algorithm described
excellent or good results may be obtained.

504 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 505

HAND AND WRIST

PAPERS PAPER NO. 362
Carpal Tunnel Syndrome: Surgical Complications
George D Chloros, MD, Winston Salem, NC (n)
PAPER NO. 361 George Sotirios Themistocleous, MD, Athens, Greece (n)
Quality and Strength of Evidence Supporting Zinon Kokkalis, MD, Athens, Greece (n)
Occupational Risk Factors for Carpal Tunnel Ioannis Benetos, MD, Athens, Greece (n)
Dimitrios G Efstathopoulos, MD, Athens-Piraeus, Greece (n)
Syndrome
Panayotis N Soucacos, MD, Athens, Greece (n)
Santiago A Lozano-Calderon, MD, Boston, MA (n)
Abstract: Carpal tunnel release is a very common operative
George Scangas, MD (n) procedure however its potential complications are underesti-
David C Ring, MD, Boston, MA mated. From 1996 to 2003, 32 patients (25 female and 7 male
(a – AO Foundation, Wright Medical) with mean age 36, range 14 to 68) were treated for complica-
Abstract: The belief that carpal tunnel syndrome (CTS) is a work- tions of carpal tunnel release in our institution. Thirty-one had
related disorder is prevalent in society in spite of the fact that been operated on elsewhere and one patient had been operated
evidence in support of this idea is limited. In contrast, there is on in our institution. Complications were: (1) median nerve
growing evidence that idiopathic CTS is a very common, geneti- injury (18 pts) including 8 injuries to the motor branch, 7 to the
cally mediated condition with little relationship to activity. We palmar cutaneous nerve, 3 incomplete lacerations of the median
undertook a systematic and quantitative analysis of the quality nerve), (2) ulnar nerve injury (7 pts) including 3 injuries to the
of scientific data in support of occupational risk factors for CTS. motor branch and 4 to the sensory branch, (3) laceration of FDS
We identified published scientific data regarding risk factors for and FDP of the index finger in association with digital nerve
CTS by searching Medline from 1981 and 2005 and by review injury (3 pts), (4) Incomplete release of the transverse ligament
the NIOSH report on occupational work-related disorders. (2 pts), and (5) deep infection - adhesive neuritis (2 pts). Mean
Forty-three scientific publications investigated direct (involving interval between initial operation and revision was 3 months
diagnosis of CTS; 31 publications) or indirect (involving meas- (range from 2 weeks to 12 months). In 19 patients nerve grafts
urement of factors believed to be associated with CTS such as were used for bridging defects whereas in 2 patients local fascial
wrist position; 12 publications) risk factors for carpal tunnel flap were used in order to enhance blood supply and gliding
syndrome. Twenty-two studies (19 direct, 3 indirect) evaluated mechanism. Patients with sensory nerve injuries suffered from
the risks associated with occupational factors. These 22 studies dysesthesias for a long time after reoperation, whereas motor

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

were compared to the remaining 21 studies for the strength of injuries recovered completely. Carpal tunnel release is not a
causal association using a 21-point quantitative scale based simple, nor a safe operation and all the appropriate precautions
upon the Bradford and Hill criteria for causal associations. must be followed.
Eighteen of 22 studies assessing occupational risk factors found
an association between occupational factors and CTS, but the PAPER NO. 363
odds ratios were weak in most studies (OR<10). The average The Biomechanical and Histologic Properties of
causal association score for occupational risk according to
Bradford and Hill criteria was 6/21 points (poor association,
Intact and Repaired Digital Nerves: An In-Vitro Study
range 4 to 10 points) compared to 8/21 (poor association, range Steven Harold Goldberg, MD, Milwaukee, WI
0 to 11 points) in the remaining 22 studies. The strongest risk (a – Orthopaedic Scientific Research Foundation)
factors for CTS were genetic 46% (statistical correlation based on Charles M Jobin, MD, New York, NY (n)
hereditability model). Even though occupational factors (Table Austin G Hayes, BS (n)
1) demonstrated some and stronger correlation, quality Tom Gardner, MCE (n)
according to Bradford and Hill criteria was very poor. Melvin Paul Rosenwasser, MD, New York, NY (n)
Temporality couldn’t be assessed, and consistency of results and
Robert J Strauch, MD, New Rochelle, NY (n)
hypothesis plausibility were significantly poor. Biological factors
(Table 1) showed weaker association; however, their quality was Abstract: Few studies have defined biomechanical properties of
higher but not significantly better. The belief that carpal tunnel intact and repaired digital nerves. Sixty-seven digital nerves from
syndrome is caused by occupational exposures is based upon 7 cadaver hands were harvested and pulled to failure (rate=20
limited data of variable quality with relatively low scores on a mm/minute). Total nerve, fascicular, and connective tissue areas
quantitative measure of causal association. Given the remark- were measured along the nerve. Thirty-eight nerves from 3
able impact of such beliefs on society, it would be irresponsible matched, paired hands were transected and microscopically
of us to support an association between occupation and CTS repaired. Repair parameters included: 2 vs. 4 epineural sutures,
without convincing evidence according to very strict criteria. 8-0 vs. 9-0 nylon, and suture purchase length of 1 or 2 mm from
Such evidence is currently lacking and CTS is most accurately the transected edge. Average digital nerve diameter was 1.8 mm,
and most optimally considered an idiopathic condition with a with the primary tactile surface of the finger having the larger
substantial genetic association. diameter (p=0.017). For normal digital nerves, the average
failure load was 6 N and stiffness was 1.2 N/m2, with nerve
tensile failure occurring proximally (72%)(p=0.001). Total nerve
and fascicular areas decreased from proximal to distal, (1.8 mm2
to 1.2 mm2) and (0.4 mm2 to 0.2 mm2), respectively (p<0.05).
Connective tissue area/fascicular area increased from proximal

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
505
PPSE 07:Layout 1 1/12/07 1:41 PM Page 506

to distal, 3.6 to 5.4 (p=0.04). Suture number was the only vari- electronode discharged 1.2mV current. Recording electrodes
able that had a significant effect on repair strength (average 2 were set on the flexor carpi ulnaris muscle (FCU) and the first
N)(p=0.015). Intact digital nerves from different fingers have dorsal interosseus muscle (FDI). The fascicle, in that high voltage
similar biomechanical properties. Digital nerve diameter was has been recorded at FCU, was selected as a donor. In patient
larger on the primary tactile side of the finger. The propensity for No.1 and 2, recovery was poor and manual muscle testing
failure at the proximal end may be partially explained by the (MMT) remained at grade 1 and 3. On the contrary, in patient
lower connective tissue to fascicle ratio. Repaired nerves fail at No.3, 4 and 5, the elbow flexion recovered well to MMT grade 4.
loads three times less than intact nerves. Similar to flexor There were three evoked potential patterns. A; FCU indicates
tendons, the primary factor in nerve repair strength is the high potential (more than 5mV) and FDI discharges moderate
number of strands that cross the repair. potential. B; Both FCU and FDI discharges moderate potential.
C; Evoked potential was low in both FCU and FDI. The patients
PAPER NO. 364 achieved powerful elbow flexion when pattern A fascicle was
Randomized Trial Comparing Standard Open selected. QIE is effective to select a donor fascicle in Oberlin’s
procedure. The fascicle, in that high voltage has been recorded at
Decompression with Technique Preserving the Skin FCU, is appropriate as a donor.
Nerves
Alexander Walter Siegmeth, MD FRCS, Vancouver, PAPER NO. 366
Canada (n) Incidence of Hand Infections and Their Bacterial
James A Hopkinson-Woolley, MBBS, Cambridge, Flora
United Kingdom (n) Clifford Dana Clark, MD, Greenville, SC (n)
Abstract: Standard treatment for carpal tunnel syndrome is open Joshua L Jones, MD, Buffalo, NY (n)
decompression. A number of patients complain of postoperative
Stephanie Lewis Tanner, MS, Greenville, SC (n)
scar discomfort. Its cause is not fully understood. We conducted
S John Millon, MD, Greenville, SC (n)
a randomized trial to investigate whether preservation of super-
ficial nerve branches crossing the incision site reduces postoper- Kyle James Jeray, MD, Greenville, SC (e – Zimmer)
ative scar pain. Forty-two patients with bilateral idiopathic carpal Abstract: Community acquired methicillin resistant staphylo-
tunnel syndrome were randomized to determine which hand coccus aureus (CA-MRSA) is an increasing concern among
was to undergo carpal tunnel decompression using a technique physicians nationwide. It typically presents as skin and soft tissue
to try and preserve the superficial nerve branches.The other hand infections, and often is confused with spider bites. The hand in
underwent open carpal tunnel decompression without any particular is a common site of presentation and anecdotal
attempt to preserve the superficial nerve branches. An assess- reports in our community have suggested a marked increase in
ment of each hand in each patient was made immediately the number of MRSA hand infections. We retrospectively
preoperatively, at sixweeks, three months and six months post- reviewed all patients with hand infections seen by an
orthopaedic surgeon in our emergency department over a 24-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

operatively. This assessment was made using a questionnaire

based on the Patient Evaluation Measure (PEM). We found no month period. 93 hand infections were identified, 70 of which
evidence of a difference in scar pain between the two methods at were community-acquired and had culture results available for
six weeks (p=0.73), three months (p=0.59) and six months review. MRSA comprised 51% of all infections over the 24-
(p=0.13). There was a significant difference in the operating time month collection period. The incidence of MRSA markedly and
between the two groups. Scar pain scores in this series of open significantly increased over time, wherein MRSA was responsible
carpal tunnel decompressions were similar, whether or not an for no cases of infection in the first 6-months of the collection
attempt was made to identify and preserve superficial nerve period and by the last 6-months it was responsible for 80% of
branches crossing the wound. all hand infections. The remaining cultures were constituted by
methicillin-sensitive Staphylococcus aureus (17%), b-hemolytic
PAPER NO. 365 Streptococcus (9%), Staphylococcus epidermitis (6%),
uncommon pathogens (3%), and no growth (13%). The litera-
Quantitative Intraoperative Electrodiagnosis in
ture is sparse in regards to the bacteriologic flora responsible for
Oberlin’s Procedure for Brachial Plexus Injury hand infections. We believe that this report has substantial
Osami Suzuki, MD, Hiroshima, Japan (n) public health implications, as CA-MRSA is not susceptible to
Toru Sunagawa, Hiroshima, Japan (n) current first line antibiotic agents. Because of this, we are
Kazunori Yokota, MD (n) currently developing a prospective trial to better define the
Toshihiro Sugioka, MD (n) proper treatment CA-MRSA hand infections.
Yasumu Kijima, MD (n) PAPER NO. 367
Osamu Ishida, MD, Hiroshima, Japan (n)
Mitsuo Ochi, MD PhD, Hiroshima, Japan (n)
Diagnostic Differences between Tuberculous and
Abstract: Nerve transfer to biceps muscle using a part of the ulnar Chronic Non-specific Tenosynovitis
nerve, described by Oberlin, is beneficial to reconstruct elbow Myung-Sun Kim, MD, Kwangju, Republic of Korea (n)
flexion for brachial plexus injury (BPI). Effectiveness of quanti- Eun-Sun Moon, MD, Kwangju-City, Republic of Korea (n)
tative intraoperative electrodiagnosis (QIE) to select a donor Bong Hyun Bae, MD, Gwanju, Republic of Korea (n)
fascicle was verified in this study. Five patients (18 to 52 years Kwang-Cheul Jeong, MD (n)
old, average 33) of BPI underwent a single fascicle transfer of the
Abstract: The purpose of this study is to identify the diagnostic
ulnar nerve. In patient No.1 and 2, no quantitative examination
differences between tuberculous and chronic non-specific
was carried out. In patient No.3, 4 and 5, all fascicles were
tenosynovitis around the wrist and the hand, which have similar
divided and QIE was performed using a commercially available
clinical, laboratory, histopathological, and radiological patterns
system (Viking IV, Nicolet Biomedical, WI, USA). Stimulating
A retrospective review was performed on 25 cases of chronic

506 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 507

tenosynovitis around the wrist and the hand, which were should be advised that triggering often takes months to resolve
divided into two groups; 10 cases of tuberculous and 15 cases of after corticosteroid injection, repeat injections are common, and
chronic non-specific tenosynovitis. Tuberculous tenosynovitis the overall success rate within 3 months is approximately 60%.
were confirmedly diagnosed by pathological biopsy and poly- Triamcinolone was superior to dexamethasone in terms of
merase chain reaction (PCR), and culture. Differential diagnoses Quinnell score, requests for surgery, and cure rate six weeks after
were made using clinical, laboratory, histopathological and injection, but not DASH, satisfaction, repeat injections, or cure
imaging studies. All patients did not respond to conservative rate at 3 months.
treatment for at least 3 months, and received tenosynovectomy.
To differentiate tuberculous tenosynovitis from chronic non- PAPER NO. 369
specific tenosynovitis, we evaluate the twelve preoperative clin- Long-term Safety and Efficacy of Injectable Mixed
ical and laboratory factors (age, gender, symptom duration prior
to surgery, size of affected area, the presence of edema, localized
Collagenase for Dupuytren’s Disease: Phase 3 Trials
warmness, neurologic deficit, leukocytes count, neutrophil ratio, Lawrence C Hurst, MD, Stony Brook, NY
lymphocyte ratio, erythrocyte sedimentation rate, complement (b – Auxilium Pharmaceuticals, e – SUNY)
reactive protein(CRP)) Three factors were found to be statisti- Marie Badalamente, PhD, Stony Brook, NY
cally significant for the diagnosis of tuberculous tenosynovitis; a (a, d – Biospecifics Tech Corp, e – Auxilium)
localized warmness, an large disease extent and an increased Abstract: Dupuytren’s disease (DD) results in finger contractures
CRP level We suggest that tuberculous tenosynovitis should be and impairment of hand function. This study evaluated long-
considered than chronic non-specific tenosynovitis if the patient term results after injection therapy with mixed collagenase
shows a localized warmness, a large disease extent, and an subtypes (AA4500, Auxilium) in DD patients. Adult patients, 19
increased CRP level of 35 who completed a randomized double-blind, placebo-
controlled study with AA4500, entered an open label study for
PAPER NO. 368 treatment failure or to treat other joint contractures. Patients
Prospective Randomized Trial Dexamethasone vs could have up to 5 additional injections of 0.58 mg AA4500 for
Triamcinolone Injection for Idiopathic Trigger Finger metacarpophalangeal (MP) or proximal interphalangeal (PIP)
joints contractures. Injection intervals were at least 4-6 weeks
Robert D Shin, MD, Kailua, HI (n)
apart. Patients were followed for 1.6 years after the last injection.
Peter Bastian, BA (n) Correction of contracture to 0-5º extension, number of injec-
Santiago A Lozano-Calderon, MD, Boston, MA (n) tions, time to achieve correction, and adverse events were deter-
Chaitanya S Mudgal, MD, Boston, MA (n) mined. In the double-blind study, 21 of 23 study drug treated
Jesse B Jupiter, MD, Weston, MA (a – AO) patients (91 percent) and 0 of 12 placebo treated patients
David C Ring, MD, Boston, MA (a – AO) achieved joint correction. In the open label study, 14 of 16 MP
Abstract: Some hand surgeons prefer a soluable corticosteroid joints (88 percent) and 13 of 19 PIP joints (68 percent) were
(e.g. dexamethasone) for trigger finger injection in order to avoid fully corrected with an average of 1.5 injections with 1 to 29 days

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

precipitate in the flexor tendon sheath. Other surgeons prefer an required for clinical success. Adverse event frequency and type
insoluable corticosteroid (e.g. triamcinolone) for its longer half- were similar to the controlled study, and included injection site
life. There are no data available to help guide the decision pain, hand edema, and ecchymosis, which resolved well. In
between corticosteroids. We performed a prospective clinical conclusion, AA4500 safely and effectively corrected MP and PIP
trial of dexamethasone vs. triamcinolone for the treatment of joint contractures in patients with 1 or more DD affected joints.
idiopathic trigger finger. Eighty-four patients were enrolled, 68 In this study, multiple injections in the same patient showed no
patients completed the six-week follow-up, and 63 patients serious or immunological adverse events. AA4500 shows
completed the three-month follow-up. Outcome measures promise as a viable alternative to surgery.
included the Disability of the Arm, Shoulder and Hand (DASH)
questionnaire, trigger finger grading according to Quinnell, and PAPER NO. 370
satisfaction on a visual analog scale (SVAS). Patients were Flare Reaction After Steroid Injection: The Role of
permitted additional injections and operative treatment at any Injection Acidity
time. The two cohorts were demographically similar. At the six-
week follow-up, the triamcinolone group demonstrated a statis-
Charles A Goldfarb, MD, Saint Louis, MO (n)
tically significant improvement in satisfaction (p < 0.05) and a Abstract: To evaluate the timing of improvement after extra artic-
trend toward improvement in Quinnell score over the dexam- ular steroid injection and the role of injection acidity in the
ethasone group (p = 0.17). At the three-month follow-up, there development of post injection pain. 93 patients with trigger
was no difference in satisfaction (p = 0.54) and a significant finger (62 patients) or Dequervains tenosynovitis (31 patients)
improvement in Quinnell score in patients receiving triamci- were prospectively randomized in this double blind study to
nolone (p = 0.01). Repeat injections were administered to 13 receive either an injection of steroid and lidocaine alone (stan-
dexamethasone and 9 triamcinolone patients at the six-week dard) or an injection of steroid, lidocaine, and bicarbonate with
folloup-up, and 1 dexamethasone and 5 triamcinolone patients a neutral pH (balanced). All patients completed a visual analog
at the three-month follow-up (p = 0.16 and p = 0.09, respec- scale (VAS) for pain before and immediately after the injection,
tively). Six patients in the dexamethasone group and only one daily for seven days, and at 6 weeks. A flare reaction was defined
patient in the triamcinolone group elected trigger finger release as an increase in the VAS score by two points any time after the
(p = 0.03). At both the six-week and three-month follow-ups, the injection. All patients immediately responded to the steroid
differences in DASH favored triamcinolone, but were not signif- injection but pain rebounded to preinjection levels by Day 1. In
icant (p = 0.20). Absence of triggering was recorded in 45% of both groups the pain then gradually declined over the course of
patients at 6 weeks and 60% of patients at 3 months with signif- 7 days. In the balanced group, 17 of the 54 patients (31%) had
icant difference seen favoring the triamcinolone group at six- a flare reaction and in the standard group, 14 of the 39 patients
weeks only (p = 0.066 and p = 0.12, respectively). Patients (36%) had a flare reaction. The difference between groups was

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
507
PPSE 07:Layout 1 1/12/07 1:41 PM Page 508

not significant (p>.05). Patients responded to extra articular under magnification. Knotted suture loops were, cyclically-
steroid injections with gradual improvement over the course of loaded, in ten Newton increments up to failure. Mode of failure
the first week. An increase in pain, or flare reaction, in the days was recorded. Knot volumes increased proportionally from two
following a steroid injection was noted in approximately one of to six throws in all materials, the greatest volume enlargement
three patients. A pH balanced injection did not significantly was recorded with Nylon (By 5.2). All FW knots had significant
decrease the risk of a flare reaction. smaller volumes than other materials. The mode of failure
changed from knot slippage, when surgeon’s knot and one
PAPER NO. 371 throw were used, to material failure when knots were secured
Potentiation of Tendon Repair and Regeneration with 4 throws. With 4 throws, Strength to failure was weakest
with Nylon (27N) and more than 35N for all other materials.
Trevor Starnes, MD, Charlottesville, VA (a – NIH)
Load to failure was increased with 6 throws and highest with FW
Deqing Huang, MD (a – NIH) at 55.8N. Comparing strength to failure between all groups with
Girish Kesturu, PhD (a – NIH) the same number of throws, FW was the strongest. Surgeon’s
Roshan James, MS (a – NIH) knot with another three square throws is essential for tendon
Gary Balian, Charlottesville, VA (a – NIH, Department of core suture security, in order to permit early mobilization after
Defense, Zimmer, DePuy-J&J, Exactech) tendon repair. Fiberwire 3-0 has the smallest knot volume and
Abhinav B Chhabra, MD, Charlottesville, VA the highest tensile strength to failure from the tendon suture
(a – NIH, DePuy-J&J) materials investigated.
Abstract: Tendon repair and regeneration is a sub-optimal
PAPER NO. 373
process controlled by multiple growth factors and cytokines.
Growth / differentiation factor-5 (GDF-5) is one of the Results of Tenodermodesis for Severe Chronic
morphogens involved in tissue regeneration, including tendon Mallet Finger Deformity in Children
repair. Mice with a null mutation in GDF-5 demonstrate
Tarik Kardestuncer, MD, Farmington, CT (n)
impaired tendon healing, manifested by altered structural and
Donald S Bae, MD, Boston, MA (n)
mechanical properties. The aim of this study is to determine the
spatial, temporal, and time kinetics of GDF-5 expression in both Peter M Waters, MD, Boston, MA (n)
normal and healing tendon and the action of recombinant Abstract: The treatment of soft tissue mallet fingers in children
human GDF-5 (rhGDF-5) in a tendon repair model. can be challenging, due to delays in diagnosis and noncompli-
Biochemical, biomechanical, and histological studies were ance with extension splinting or casting. The purpose of this
completed following in vivo rhGDF-5 treatment in a rat Achilles investigation was to assess the results of tenodermodesis for the
tendon repair model. Temporal immunolocalization of GDF-5 treatment of chronic soft tissue mallet fingers in children. A
in normal and repairing tendon was performed with antibodies. retrospective analysis of 10 patients below 18 years of age was
rhGDF-5 treatment increased tendon diameter, improved performed. All had extensor lag greater than 45 degrees, absent
collagen fiber orientation and enhanced cell and tissue organi- active distal interphalangeal joint (DIPJ) extension, and full
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

zation. Total hydroxyproline increased upon treatment with passive DIPJ motion. All patients had failed trails of non-opera-
rhGDF-5; accompanied by an increase in tensile strength in tive treatment. Tenodermodesis was performed using estab-
tendons treated with higher doses. The distribution of GDF-5 lished techniques with 4 to 6 weeks of postoperative DIPJ
was biphasic, with the highest levels detected early at 10 hours immobilization. Patients were evaluated for active and passive
after repair, and again at day 10. The results indicate that treat- DIPJ motion, deformity, pain, functional limitations, and the
ment with rhGDF-5 protein increases the amount of collagen need for additional treatment. Average age at the time of surgery
during tendon repair and improves collagen orientation and was 7.4 years (range 1.4 to 17.8 years). At average 6.5 year
tensile strength, thereby enhancing tendon healing. Since surgi- follow-up (range 1 to 12.8 years), all patients demonstrated
cally repaired tendon lacerations are weakest between 10-14 days restoration of active DIPJ extension and improvements in
postoperatively, further investigations with rhGDF-5 treatment extensor lag. Two patients (20%) achieved full active DIPJ exten-
will determine the temporal injection periods that maximize the sion, while eight patients (80%) had persistent extensor lag of 20
benefits of treatment either by injection or through a surgical degrees or less. Seven patients (70%) maintained full active DIPJ
delivery system with a bioresorbable scaffold. flexion. Eight of the ten patients (80%) reported full return to
activities with no functional limitations. No patients required
PAPER NO. 372 additional surgical treatment for their mallet fingers.
Tenodermodesis is a safe and effective technique for the treat-
The Effect of Number of Throws on Knot Volume
ment of severe chronic mallet finger deformities in children.
and Security of Common Tendon Suturing Materials While patients and families should be advised of mild persistent
Steve K Lee, MD, New York, NY (n) extensor lag and limitations in DIPJ motion, active DIPJ exten-
Mordechai Vigler, MD, Brooklyn, NY (n) sion and improved clinical appearance can be achieved.
Ram Palti, MD, New York, NY (n)
Eric Strauss, MD, New York, NY (n) PAPER NO. 374
Steve Green, MD (n) Effects of the Deep Anterior Oblique and Dorsoradial
Abstract: When suturing tendons, the strength of the core suture Ligaments on Trapeziometacarpal Joint Stability
and its knot security are critically important. When repairing Matthew Colman, BA, Chicago, IL (n)
flexors in the digital sheath the knot’s volume may increase Daniel Paul Mass, MD, Chicago, IL (n)
suture bulk and work of flexion. A mechanical study was
Louis F Draganich (n)
performed to assess the effect of the number of throws on knot
Abstract: Osteoarthritis of the trapeziometacarpal joint of the
volume and strength in four common suture materials, using 3-
thumb affects as many as twenty five percent of post-
0: Prolene, Ethilon, Fiberwire(FW) and Ethibond. Knot groups
menopausal women. This study investigated the relative contri-
consisted of two to 6 throws. Knot dimensions were measured

508 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 509

bution of the dorsoradial ligament (DRL) and deep anterior time-consuming repair, and an anatomic ligament reconstruc-
oblique ligament (dAOL) in limiting movement of the thumb in tion. Both techniques effectively restored DRUJ stability after
order to determine the relative contribution to stability of the pTFCC tear. Clinical comparisons are underway.
trapeziometacarpal joint. This knowledge would improve our
understanding of the pathomechanics of osteoarthritis at the PAPER NO. 406
base of the thumb and may inform reconstructive surgical Prospective Randomized Comparison: Early vs. Late
strategy. Seventeen intact cadaver hands were dissected to reveal
the DRL and dAOL. Either the DRL or dAOL was randomly tran-
Wrist Motion Post ORIF for Distal Radius Fractures
sected, physiologic muscle loads were applied to simulate lateral Santiago A Lozano-Calderon, MD, Boston, MA (n)
key pinch or thumb opposition, and a three-dimensional Chaitanya S Mudgal, MD, Boston, MA (n)
magnetic tracking system was used to record the position of the Jesse B Jupiter, MD, Weston, MA (a – AO Foundation)
first metacarpal relative to the trapezium. The differences in the David C Ring, MD, Boston, MA
three-dimensional positions between the control and transected (a – AO Foundation, Wright Medical)
states were determined. In lateral pinch, transection of the DRL Abstract: The claimed advantage that plate and screw fixation of
resulted in a mean increased three-dimensional translation of the distal radius will result in better wrist motion by allowing
1.3mm, while transection of the dAOL resulted in mean earlier initiation of exercises has not, to our knowledge, been
increased three-dimensional translation of 0.6mm. Significant tested scientifically. We performed a clinical trial of early vs. late
two-dimensional findings after transecting the DRL or dAOL mobilization of the wrist after volar plate fixation of a fracture of
included an increased palmar translation of 0.3mm and 0.2mm, the distal radius to test the hypothesis that early wrist mobiliza-
an increased radial (1.0mm) and ulnar (0.3mm) translation, tion improves ultimate wrist function. 42 patients have enrolled
and an increased pronation of 4.1 degrees and 2.4 degrees, to this point, 20 were allowed to begin moving their wrist at the
respectively. In most degrees of freedom of metacarpal move- time of suture removal and 22 had the wrist immobilized until
ment relative to the trapezium, the DRL is relatively more impor- six weeks after surgery. We anticipate reaching our enrollment of
tant than the dAOL in providing stability to the 60 total patients according to power analysis by August 2006
trapeziometacarpal joint. and anticipate 90% completion of the protocol by the time of
the annual meeting. This abstract reports preliminary results for
PAPER NO. 375
31 patients evaluated at 3 months (15 early, 16 late cohorts), and
Mechanical Testing of Distal Radioulnar Instability 22 that have completed the study (11 early, 11 late cohorts).
Repair: Ligament Reconstruction vs Capsulorraphy There are no significant differences in the DASH score at 3
months: 21(early) vs. 24(late) and 6 months: 15(e) vs. 13(l); 3
Christopher J Dy, BS, Miami, FL (n)
months Likert pain score: 6(e) vs. 4(l) and 6 months: 1.2(e) vs.
Elizabeth A Ouellette, MD, Miami, FL (n)
1.3(l); wrist flexion-extension arc: 99°(e) vs. 94°(l) at 3 months
Ali Malik, MS, Davie, FL (n) and 118°(e) vs. 123°(l) at 6 months; grip strength: 34 pd(e) vs.
Veronica A Diaz, MD, Miami, FL (n) 43 pd(l) at 3 months and 58 pd(e) vs. 45 pd(l); and Mayo wrist

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

Anna Lena Makowski, MS, Miami, FL (n) score (63 vs. 64 and 74 vs.73) at any time point. There were not
Edward L Milne, BSc (n) statistically significant differences between groups when inde-
Andre Barreto, MS (n) pendent single and paired T tests analysis were performed. All
Loren L Latta, PhD, Plantation, FL (n) fractures healed and no complications have been identified. The
Abstract: Instability of the distal radioulnar joint (DRUJ) pres- contention that internal plate-screw fixation is advantageous
ents a therapeutic challenge to physicians, with management because it allows earlier mobilization of the wrist leading to
varying according to the pathomechanics of the lesion. Extensive improved wrist function is not supported by scientific data.
injury to the TFCC, the major stabilizing structure of the DRUJ,
is increasingly repaired via radioulnar ligament reconstruction.
PAPER NO. 407
An alternative procedure, a capsulorraphy, has been proposed ◆Phase 3 Acceleration of Distal Radius Fracture
and used by the investigative team with clinical and biome- Healing with a Thrombin Receptor Binding Peptide
chanical success. This study is a comparison of clinical and
Amy L Ladd, MD, Palo Alto, CA (e – Orthologic)
biomechanical stability following ligament reconstruction and
capsulorraphy. Nine fresh-frozen cadaver arms were examined Alexander Yong Shik Shin, MD, Rochester, MN
using fluoroscopy and biomechanical testing. Ulnocarpal insta- (a – Orthologic)
bility was reproduced by manual division of the dorsal and volar Dale G. Bramlet, MD, Saint Petersburg, FL (a – Orthologic)
radioulnar ligaments, creating an ulnar-sided peripheral TFCC Scott W Wolfe, MD, New York, NY (a – Orthologic)
tear. The stability of the DRUJ was restored using the capsulor- James T Ryaby, PhD, Tempe, AZ (e – Orthologic)
raphy in four specimens and anatomic ligament reconstruction Abstract: Chrysalin (TP508), a synthetic thrombin receptor
in five specimens. All limbs were evaluated in pre-repair and binding peptide, has demonstrated fracture healing acceleration
post-repair conditions. Change in radioulnar stiffness was eval- in pre-clinical animal studies and an initial Phase 1/2 human
uated using the mechanical testing system. Both repair tech- clinical trial. This Phase 3 study evaluated Chrysalin in a large
niques resulted in a statistically significant increase in stiffness multicenter distal radius fracture population. This prospective,
(p<0.05) when comparing pre-repair and post-repair radioulnar double blind, randomized placebo controlled two-arm IND
stiffness. When comparing the radioulnar stiffness ratios for each clinical trial compared one dose (10ug) of Chrysalin to placebo
specimen before and after repair, there was no significant differ- (saline) in 503 subjects in 27 US centers. Subjects with unstable,
ence between the ligament reconstruction and the capsulor- displaced distal radius fractures were randomized based on
raphy. These results suggest that there is no statistically extra- or intra-articular fractures, and Chrysalin or placebo was
significant difference when comparing post-repair stiffness with administered as a single intrafracture percutaneous injection.
the capsulorraphy procedure, which is a less invasive and less Subjects were followed weekly for the first 8 weeks with addi-

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
509
PPSE 07:Layout 1 1/12/07 1:41 PM Page 510

tional visits at 10, 12, and 26 weeks. DXA analysis characterized patients presenting to our institution with a distal radius fracture
subjects as normal, osteopenic, and osteoporotic. Incidence of were entered into a prospective database. Baseline functional
adverse events and serology/ urinalysis results determined safety and radiographic data were obtained. At each follow up, patients
evaluation. No treatment group had differences in safety param- were examined for complications associated with fractures and
eters. The primary endpoint, time to immobilization removal, operative care. All complications were noted and followed for
was not statistically reduced in the Chrysalin compared to resolution of symptoms and need for further treatment. A
placebo group. Radiographic secondary endpoints showed Fisher’s Exact test was used to compared groups. 338 patients
significant differences. Statistically significant acceleration of qualified for admission into the study. For analysis we divided
radial cortical bridging occurred in Chrysalin subjects in the the cohort into 4 groups: closed reduction and casting n=169,
overall evaluable subject population, p=0.046. Statistically external fixator with supplemental K-wire fixation n=57, locked
significant acceleration of radiographic healing occurred in volar plating n=108 and closed reduction and percutaneous
Chrysalin subjects with extra-articular fractures, p=0.027. These pinning n=4. The incidence of complications in the Non-opera-
differences were observed as early as three and four weeks post- tive group was 11.2 percent, the external fixation group was 36.8
treatment with Chrysalin, a benefit also observed in the Phase percent, the ORIF group was 30.6 percent and the closed reduc-
1/2 clinical trial. The results demonstrate safety and additional tion and percutaneous pinning group was 75 percent. There
efficacy of Chrysalin for accelerating fracture healing in the distal were significantly more complications in the operative group
radius based on radiographic imaging, and provides the basis for compared to the non-operative group (p less than 0.001). There
the ongoing Phase 2b clinical dosing trial. were 7 unplanned returns to the operating room in the ORIF
group, one in the external fixation group and none in the non-
PAPER NO. 408 operative and closed reduction and percutaneous pinning
Sensitivity of Fluoroscopy in Determining Screw group. Patients treated for distal radius fractures have more
complications than appreciated.Incidence of complications
Position in the Distal Radius between operative and non-operative treatment differs greatly.
Jeffrey A. Greenberg, MD, Indianapolis, IN (n)
Andrew Thomas, MD (n) PAPER NO. 410
Abstract: This study evaluates the sensitivity of fluoroscopy for Screening and Treatment for Osteoporosis
detecting screw position in the dorsal distal radius. 2.4 mm
screws were placed from volar to dorsal in the radial, central, and
Following Fractures of the Distal Radius
ulnar thirds of cadaveric distal radii. Screws were placed 1 mm Tamara D Rozental, MD, Boston, MA (n)
shy of cortex, flush to bone, 1 or 2 mm proud of cortex. Eric Makhni, BS, Boston, MA (n)
Fluoroscopic images were then produced, intentionally making Charles S Day, MD, Boston, MA (a – Wright Medical, SBI)
the screw appear as proud as possible. Evaluators with different Abstract: A prior fragility fracture increases the risk of future frac-
years of experience were then asked to assess screw position. ture by 50%, yet reported screening rates for osteoporosis after
Results were stratified by the position of the screw in the distal such injuries are low. The purpose of this study is to determine
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

radius and by the evaluator’s years in practice. Combining all screening and treatment rates for osteoporosis following distal
evaluators, fluoroscopy was found to be 72% sensitive at radius fractures (DRF) in an outpatient, tertiary care, orthopaedic
detecting screw overshoot in the radial-most position, 75% practice. The records of 298 consecutive patients over age 50 with
sensitive in the central position and 54% sensitive in the ulnar fragility DRF seen in our practice between 2002 and 2005 were
position. Evaluators with greater than three years practice expe- reviewed. Outcomes measures were a bone mineral density scan
rience determined screw position with 100%, 94% and 78% (BMD) and treatment with osteoporosis medication within 6
sensitivity in the radial, central, and ulnar positions, respectively. months of fracture. 240 patients (181 women, 59 men) at an
Evaluators with less than three years experience were less effec- average age of 68.4 (50-102) with medical complete records were
tive, predicting screw position with 63%, 60%, and 56% sensi- included. Prior to DRF, 30% of patients had a BMD; 78% of
tivity in the radial, central and ulnar positions, respectively. patients had never been treated for osteoporosis and 22% were
Fluoroscopy is a less sensitive method to determine screw over- on medication. Following DRF, 22% of patients underwent a
shoot in the ulnar aspect of the dorsal distal radius, particularly BMD: 7% had a normal BMD, 58% were osteopenic and 35%
with less experienced hand surgeons. Based on the data were osteoporotic. After DRF, 72% of patients received no osteo-
presented here, surgeons should have a low threshold for screw porosis medication, 7% were on Ca/vitD, 11% were on biphos-
exchange when presented with possible screw overshoot. phonates, 3% had hormone replacement therapy and 7% were
on a combination regimen. 10% of patients had a change in
PAPER NO. 409 treatment following DRF. Patients with a BMD had treatment
Early Complications of Distal Radius Fractures: rates of 54% compared to 23% in those without. At 22% and
28% respectively, screening and treatment rates for osteoporosis
Operative and Non-Operative Treatment
are exceedingly low. Screening with BMD increases the rate of
Nader Paksima, DO, New York, NY (n) treatment to 54%. Future efforts should focus on initiating
Nirmal C Tejwani, MD, New York, NY osteoporosis screening in the orthopedic clinic as well as active
(a – Stryker Howmedica) communication with primary care physicians.
Toni M McLaurin, MD, New York, NY (n)
Mike Walsh, PhD (n)
Ericka Ann Lawler, MD, Iowa City, IA (n)
Kenneth A Egol, MD, New York, NY (n)
Abstract: To determine the incidence of early complications
associated with operative and non-operative treatment of frac-
tures of the distal radius, and complications associated with
external fixation versus internal fixation. Over a 2 year period all

510 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 511

PAPER NO. 411 nonunions) did return to their activity of injury but did not
Percutaneous Transtrapezial Fixation of Acute perform at the previous level. This study demonstrates that
scaphoid nonunions with AVN can be successfully treated using
Scaphoid Fractures internal fixation and a VBG, resulting in significant improve-
Geert Meermans, MD, London, United Kingdom (n) ments in both objective and subjective outcome measures.
Frederik Verstreken, MD, Deurne, Belgium (n)
Abstract: Percutaneous fixation is an accepted treatment method PAPER NO. 413
in acute scaphoid fractures. Fracture healing and biomechanical Recessed Radioscapholunate Arthrodesis for
strength have been shown to be best when the screw is placed Isolated Radiocarpal Arthritis
centrally. This is often difficult to obtain through a standard
volar approach because of blocking of the trapezium. The William H Seitz Jr, MD, Cleveland, OH
purpose of this study is to examine a new percutaneous (a – Trimed, e – SBI)
transtrapezial approach for the fixation of scaphoid fractures. Chad Manke, MD, Virginia Beach, VA (n)
The outcomes of acute scaphoid waist fractures, fixed Abstract: Radiocarpal arthritis resulting from degenerative or
transtrapezially from 2000 until 2004 were evaluated. The wrist posttraumatic conditions is a debilitating process with limited
was protected by a splint for 2 weeks. Results were graded with treatment options. If the lunate facet remains reasonably
use of the modified Mayo wrist score. Repeat radiographs were congruent, proximal row carpectomy has been shown to be an
taken to assess screw position and scaphotrapezial osteoarthritis. effective treatment modality. When the lunate fossa deteriorated
41 patients were included in our study. The follow-up time however, there have been few motion-sparing procedures which
ranged from 14 to 68 months. There was a 100% union rate with have been effective leaning total wrist arthrodesis procedure of
an average time to union of 6,4 weeks. According to the modi- choice. In the face of radiocarpal arthritis with a relatively
fied Mayo wrist score there were 4 good and 37 excellent results. healthy mid carpal joint, the authors have devised a form of
Radiographs showed central placement of the screw in all limited radiocarpal arthrodesis to allow enhanced motion
patients. In 3 patients the screw was removed. One patient devel- through the mid carpal joint. Twelve patients with radiocarpal
oped a CRPS type 1 reaction. Clinically and radiographically, arthritis (4 patients following failed treatment of complex distal
there were no degenerative changes of the scaphotrapezial joint. radius fractures, 4 patients with scapholunate advanced collapse,
Percutaneous transtrapezial fixation is an easy and accurate tech- 2 patients with scaphoid nonunion with advanced collapse and
nique for central screw placement in acute scaphoid waist frac- 2 patients following failure of treatment for transcaphoid perilu-
tures. This allows early return to daily activities. Midterm results nate fracture dislocation) were treated with a procedure to recess
showed no evidence of scaphotrapezial osteoarthritis. We the lunate and proximal pole of scaphoid into the metaphyseal
believe that this technique is optimal for the treatment of acute bone of the distal radius, resection of the distal one half of the
scaphoid waist fractures in a young and active population. scaphoid was also performed to allow enhanced motion of the
capitate head within the fossa of the lunate and proximal
PAPER NO. 412 scaphoid to the radius as a ‘universal joint’. Fixation of the lunate

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

Outcome After Vascularized Bone Grafting of and proximal scaphoid was achieved through modified tension
pin plates. Controlled early active motion was begun one week
Scaphoid Nonunions with Avascular Necrosis after surgery (patients have been followed for an average of 2.8
Leonid Iwan Katolik, MD, Seattle, WA (n) years, range 2-4 years). All 12 patients developed a stable union
Wren V McCallister, MD, Seattle, WA (n) at the arthrodesis site. None had hardware problems and there
Thomas E Trumble, MD, Seattle, WA (n) were no infections. Range of motion increased from an average
Abstract: This prospective study evaluated the subjective and preoperative total arc of flexion-extension of 32 degrees to a total
objective outcome after treatment of scaphoid nonunions with arc of flexion extension of 68 degrees (range 42 degrees to 110
avascular necrosis (AVN) using internal fixation and a vascular- degreed). Pain ratings on a visual analog scale decreased from an
ized bone graft (VBG). From 1994-2002, 32 patients with average of 8.7 to 1.2. Eleven of 12 patients demonstrated a
scaphoid nonunions and MRI-documented AVN (20 waist, 12 significant increase ability in their activities of daily living. Of the
proximal pole) underwent ORIF and a 1,2 IC SRA VBG. five patients who had been gainfully employed prior to surgery,
Preoperative and postoperative evaluation, measurements made all five had returned to work at their regular job. Patients who
by independent evaluators, included clinical (grip strength, participated in recreational activities and had been prevented
composite range of motion), radiographic (scapholunate angle, from doing so prior to surgery (tennis, golf, fishing, bowling)
height-to-length ratio, radioscaphoid arthritis) and outcome were able to resume their recreational athletic activities. One
parameters (DASH, VAS satisfaction scale). Union and return to patient had persistent stiffness and was not pleased with his
activity were recorded. Data was analyzed both in the aggregate limited motion but had significant pain relief. Radiographic
and stratified by nonunion location. Mean follow-up=21 analysis has shown deterioration of the mid carpal articular
months (range 13-35). Union rate after index procedure=88%, surfaces in only one of the 12 patients. Limited radioscapholu-
overall union rate=94%. Time to union (TTU)=5.1 months nate recessed arthrodesis with excision of the distal half of the
(±2.43) (TTU scaphoid waist=4.1 months vs. proximal pole=5.4 scaphoid appears to be a viable motion sparing procedure for
months, p<.02). Significant improvements: grip strength, DASH isolated radiocarpal arthritis. Although there are limitations in
score, VAS satisfaction scale, scaphoid height-to-length ratio, no the total degree of movement, the motion which persists is func-
preexisting radioscaphoid arthritis, p<.001. No difference for tional, pain relief has been substantial and the short term (2-4
composite wrist ROM. Complications: 2 patients who required year) follow-up suggests minimal deterioration. This procedure
a second procedure to achieve union. Two patients with preex- is technically straight forward and appears to be a good alterna-
isting grade 3 radioscaphoid arthritis, failed to unite and were tive to total wrist arthrodesis when the mid carpal joint is
treated with scaphoid excision and intercarpal arthrodesis. 91% reasonably spared. The key to enhanced motion through the
of patients returned to their job or sport of injury at their pre- mid carpal joint is resection of the distal 1/2 of the scaphoid.
injury level. Of the remaining 3 patients, 2 (scaphoid waist

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
511
PPSE 07:Layout 1 1/12/07 1:41 PM Page 512

PAPER NO. 414 of implantation was 65 years (39-75). Average follow-up was 12
Management of Complications of Limited Wrist months (3-48). There was no statistically significant difference
between ranges of motion preoperatively or post-operatively
Arthrodesis between groups based on diagnosis, gender, or implant type.
Martin Charles Skie, MD, Toledo, OH (n) Complications included one swan neck deformity, one deep
Nicholas Gove, MD, Carmel, IN (n) infection, one dislocation (early), and 2 flexion contractures.
Abstract: Wrist degeneration, resulting from scaphoid non-union Proximal interphalangeal joint arthroplasty is known to be an
or scapholunate ligamentous disruption, is widely managed with effective method of relieving pain while preserving motion in
scaphoid excision with four corner fusion. There are no specific the damaged PIP joint. This study shows that PIP joint arthro-
details in the literature regarding ‘salvage’ of non-union following plasty can be successfully implemented through a volar
attempted ‘four corner fusions’ or the patient outcomes. The approach with a variety of implant types with favorable
purpose of this paper is to present the results of patients who outcomes when compared to the dorsal approach.
underwent treatment for non-union following four-corner
fusion, the subsequent surgeries done for wrist salvage and the PAPER NO. 416
functional results. We reviewed retrospectively thirty-seven Complications in Percutaneous Screw Fixation of
patients who underwent limited wrist fusion using circular plate Scaphoid Fractures
fixation, of which eight cases (22%) went on to non-union and
necessitated further surgeries. The average follow-up period after Brandon D Bushnell, MD, Durham, NC (n)
subsequent surgeries done for complications of four-corner Andrew McWilliams, MPH, Chapel Hill, NC (n)
fusion was 34 months. Five of eight patients were available to Terry M Messer, MD, Raleigh, NC (n)
return to the clinic and the wrist range of motion and the DASH Abstract: With advances in tools and techniques, percutaneous
score were recorded. The average DASH score was 46 (range 15 to screw fixation of nondisplaced or minimally-displaced fractures
60.8). Grip on the affected limb was on the average 62% of the of the scaphoid has gained increasing popularity in recent years
contralateral limb. Average arc of wrist motion was 70 degrees as an alternative to prolonged cast immobilization. Many
(35.7 degrees of flexion and 34.3 degrees of extension). Three of reports cite very low complication rates, including no complica-
the five patients were laborers and two returned to the previous tions in some series. We present our experience with the tech-
employment. The remaining two patients returned to their nique and the complications we have encountered. A
previous sedentary jobs. All patients reported difficulty with retrospective chart review was performed on the 24 patients of
recreational activities involving heavy activity. Although this is a the senior hand surgeon at a Level I trauma center who under-
small series, the patients obtained similar range of motion and went surgery between October 2001 and August 2006. All cases
grip strength as those in the literature, but did score worse on involved dorsal percutaneous screw fixation of nondisplaced or
DASH testing, indicating more disability. This may have been in minimally (<1mm) displaced fractures of the scaphoid waist or
part to the prolonged course of treatments in these patients, as proximal pole. Of the 24 patients reviewed, 3 lacked adequate
many nonunions were identified once the screws began backing follow-up. Twenty of the 21 remaining patients healed (95%),
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

out as the plate obscured the nonunion site. This should prompt with one patient requiring revision surgery for nonunion.
surgeons to carefully examine the technical aspects of performing Average time until radiographic healing was 18 weeks overall, 10
the four-corner fusion operation with a Spider Plate and be vigi- weeks for nonsmokers, and 32 weeks for smokers. Smoking had
lant in locating those non-united fusions. Although salvage is a statistically significant effect on healing (p=0.021). The overall
possible, the patient may face a prolonged course of treatment complication rate was 29%, with 19% major complications and
and significant disability. 10% minor complications. Major complications consisted of the
one case of nonunion and three cases of painful hardware
PAPER NO. 415 requiring removal. Minor complications included intraoperative
The Volar Approach to Proximal Interphalangeal equipment breakage - one case involving a screw and one case
involving a guide wire. Most of these complications occurred
Joint Arthroplasty early in the learning curve for this procedure, and almost all of
Scott F M Duncan, MD, Phoenix, AZ (n) them resulted from technical errors. Percutaneous screw fixation
Anthony Smith, MD, Scottsdale, AZ (n) of scaphoid fractures can result in rapid, reliable healing, but the
Marianne Merritt, RNFA (n) surgeon must meticulously adhere to proper technique to
Kevin J Renfree, MD, Scottsdale, AZ (n) reduce the risk of complications.
Abstract: Most hand surgeons currently utilize a dorsal approach
for placing arthroplasty implants into the proximal interpha-
PAPER NO. 417
langeal joint. The purpose of this study was to examine the clin- Osteotomy of the Base of the First Metacarpal for
ical outcomes of patients undergoing proximal interphalangeal the Thumb Osteoarthritis
joint arthroplasty through the less commonly applied volar
Daniel Esteban Balassanian, MD, Buenos Aires, Argentina
approach. This was a retrospective chart review examining the
results from patients undergoing PIP joint arthroplasty through (n)
a volar approach between 2001 and 2005 by three fellowship Armando C Rebechini, MD, Buenos Aires, Argentina (n)
trained hand surgeons at our institution. Indications for surgery Andres Napal, MD (n)
were PIP joint pain with radiographic evidence of joint destruc- Carlos Bertolini, MD (n)
tion. Variables examined included: type of implant, diagnosis, Abstract: Trapeziometacarpal osteoarthritis is a degenerative
digit, pre/post operative range of motion, and complications. disorder characterized by pain in the base of the thenar
Over this five year period 25 PIP joints were replaced in 20 eminence and adduction deformity of the thumb, with abrasion
patients utilizing the volar approach. These consisted of 14 and progressive damage of the articular surfaces. According to
Advanta semi constrained prostheses, 9 Ascension (pyrocarbon) Eaton-Glikel classification, we performed an osteotomy of the
prostheses, and 2 silicone prostheses. The average age at the time base of first metacarpal for stages II and III. Between January

512 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 513

1994 and December 2003, forty-seven osteotomies of the base lengthenings have been performed over a nine year period with
of the first metacarpal have been performed in 47 patients (37 follow-up ranging from one to eight years. Skeletal segments
women an 10 men), with trapeziometacarpal arthritis, stages II lengthened include the humerus in five cases, radius in one, ulna
and III, according to Eaton-Glikel classification. The operation in seven, metacarpals in thirty-four, and phalanges in fifty-six.
technique was performed through a standard dorsal approach of Indications for lengthening have included severe congenital defi-
3 cm over the radial border of the first metacarpal. We make a V- ciency of the humerus, radial club hand, and hypoplastic or
shaped osteotomy, 2 cm distal to the joint line, osteoclasis, while absent finger rays as well as posttraumatic deficiencies due to
structural support is provided by internal fixation. We evaluate segmental bone loss and amputations at multiple levels.
pain, hand function, and patient satisfaction. Follow-up ranged Lengthening has ranged between twenty and four hundred
24 months to 7.2 years. 93.7 % were enthusiastic or satisfied at percent of the original length of the skeletal segment elongated.
the last follow-up. Overall complications rate was 10.25 % (4 Primary neo-osteogenesis has been archieved in 94% of cases
patients). There were no major operative complications. Relief of with only 6% requiring supplemental bone grafting. Major
pain was observed in almost all cases, with adequate grasping complications have occurred in 9% of lengthenings while minor
and stable articulation, keeping the length of the first metacarpal complications (most commonly pin tract infections) have
axis. The most impressive finding was the relief of pain. This occurred in 46% of cases but have resolved without significant
alternative technique is easy to perform. Provides useful painless sequelae. Complications have provided the impetus for
digital grasping. It gives quite good results for years with few improved techniques and have spurred research into improved
complications. methods of combining elongation with enhanced function. In
all cases elongation was undertaken for enhanced function.
PAPER NO. 418 Therefore a functional follow-up evaluation was performed
Hylan vs Steroid vs Placebo Injection for Thumb which demonstrated improved prosthetic wear in individuals
where stumps were lengthened for improved mechanical advan-
Basal Joint Arthritis: Two-Year Unblinded Follow Up tage; two point discrimination and dexterity demonstrated
Charles M Jobin, MD, New York, NY (n) enhanced ability to manipulate fine objects, use writing instru-
Clemment J Bottino, MD, New York, NY (n) ments and perform activities of daily living, while maintaining a
Erick Rizzotto, BS, New York, NY (n) stable degree of both protective and discriminatory sensation
Robert J Strauch, MD, New Rochelle, NY (a – Genzyme) throughout the lengthening process with preservation at the
Melvin Paul Rosenwasser, MD, New York, NY (a – Genzyme) time of final evaluation. Protection of physeal plates in skeletally
Abstract: Intra-articular corticosteroid and hyaluronan derivative immature patients has demonstrated persistent growth of the
injections are treatments for osteoarthritis. This study compared lengthened part while lengthening in the absence of a healthy
the subjective outcomes two years after thumb carpometacarpal physeal plate or through previously transplanted bone has
intra-articular injections of hylan-GF20, corticosteroid, or saline. generated a need in some cases for secondary lengthening.
Sixty patients previously enrolled in a blinded RCT were sent a Family and patient satisfaction rates are extremely high with
follow up survey to evaluate current thumb pain (VAS), satisfac- 95% of patients demonstrating a willingness to undergo this

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

tion, splint, therapy, and pain medication usage, and willingness surgery a second time in order to achieve the same functional
to repeat or recommend injections. Pre-enrollment AP radi- result. Although there is a longer duration of time necessary for
ographs were graded for Eaton score, metacarpal subluxation, consolidation of bone than needed with prior techniques of
and joint-space narrowing and were correlated to pain levels. At rapid lengthening and bone graft interposition, the current tech-
an average of 27 months follow up, 52 of 60 patients (87%) nique of callotasis lengthening has obviated the need for a
responded to the survey. Groups were similar at baseline. Two second operative procedure (in most cases for bone grafting)
steroid and two hylan patients received basal joint arthroplasty and has reduced the morbidity associated with this second
with an incidence of 3.3% per year. The hylan group reported procedure. The slow lengthening technique utilized has also
significantly less pain (2.5cm) compared to saline (5.0cm) demonstrated an acceptable level of comfort throughout the
(p=0.01), and trended toward improvement compared to steroid lengthening and consolidation period.
(4.5cm) (p=0.075). There were no differences between groups in
PAPER NO. 420
therapy status, splint usage, pain medication usage, or willing-
ness to repeat or recommend injections. Joint space narrowing The Use of a Type I Lyophilisate Collagen as
and metacarpal subluxation, but not Eaton grade, correlated Osteoinductive Factor in Pseudoarthroses of the
with pain (p<0.05). Intra- and inter-rater kappa values for Eaton
grading were 0.47 and 0.30, respectively. In the long term, intra-
Forearm
articular hylan injections reduced pain in carpometacarpal Michael Strassmair, MD, Starnberg, Germany (n)
thumb arthritis better than saline or corticosteroid. Radiographic Hans Bosebeck, PhD (n)
joint-space narrowing and metacarpal subluxation correlated Michael A Mont, MD, Baltimore, MD (n)
with increased pain at two-years. In our opinion, hylan injec- Thorsten M Seyler, MD, Baltimore, MD (n)
tions are an effective long-term treatment for basal joint Abstract: Aseptic pseudarthrosis of the ulnar or radial diaphysis
osteoarthritis of the thumb. after isolated shaft fractures is a rare complication that is
frequently the result of inadequate immobilization and/or
PAPER NO. 419 surgical fixation. Pseudarthrosis may cause forearm deformity
Results of Callus Distraction Lengthening in the and functional compromise of the upper extremity and thus,
Hand and U/E for Skeletal Deficiencies requires urgent surgical treatment. The purpose of this study was
to review the results of diaphyseal forearm pseudarthroses that
William H Seitz Jr, MD, Cleveland, OH (e – Stryker) were treated with repeated surgical fixation and the use of a
Abstract: One hundred and three individual lengthenings have novel bone void filler consisting of Type I collagen and various
been performed over a nine year period with follow-up ranging growth factors including VEGF, TGF²-1, TGF²-2, IGF-1, BMP-2,
from one to eight years. One hundred and three individual BMP-3, and BMP-7. Between January 2000 and December 2003,

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
513
PPSE 07:Layout 1 1/12/07 1:41 PM Page 514

eleven patients underwent an osteosynthesis procedure for cycles up to 100N were 0.05mm±0.02SD (headed metal),
isolated pseudarthrosis fractures of the forearm. Their mean age 0.14mm±0.14SD (headless metal) and 0.29mm±0.11SD
was 39 years (range, 24 to 54 years). All patients initially failed (composite) and differed significantly (p<0.01). Using tolerance
operative fixation of the fracture and histological analysis limits, the data allowed us to predict that with 95% certainty, the
confirmed the presence of a pseudarthrosis. There were six maximum average translation (step-off) following severe
pseudarthroses of the radial diaphysis and five of the ulnar loading in 95% of any sample fixed with a headed metal screw
diaphysis. Under fluoroscopic guidance using a minimally inva- will be below 0.17mm, headless metal screw below 0.74mm,
sive technique, debridement and decortication of the nonunion and composite screw below 0.76mm. Comparing two types of
was performed. The bony defect was then filled with the novel metal screws and a new composite bio-absorbable screw to
bone void filler, and stable surgical fixation was obtained. All maintain scaphoid fixation under cyclic loading conditions, we
patients underwent radiographic evaluations at two-week inter- we found no gross failure or fracture gap displacements and only
vals following re-operation until solid union was achieved. The small average translations (step-off) for all three screws.
mean duration between initial surgical fixation and re-operation Moreover, translations of more than 1 mm that would predis-
(present index procedure) was 8.5 months (range, 5 to 14 pose to non-union were highly unlikely for any of the screws,
months). The first radiographic signs of fracture healing after the even after severe cyclic loading. We therefore conclude that a new
application of the bone void filler were noted at a mean of 4.7 bio-absorbable composite screw can serve as an alternative to
weeks (range, 4 to 6 weeks) and complete fracture consolidation conventional screws when fixing scaphoid fractures.
was achieved in all patients at a mean of 6.2 weeks (range, 6 to
8 weeks). Patients demonstrated improved range of motion and POSTER NO. P225
grip strength. In addition, all patients were pain free at the 6- Outcomes after Treatment of Comminuted PIP
week follow-up visit. With regard to safety, no adverse effects
associated with the use of the equine bone derived novel bone
Fracture-Dislocations with a Dynamic External
void filler were encountered. The combination of a novel equine Fixator
bone derived bone void filler and stable internal fixation Scott Ellis, MD, New York, NY (n)
predictably led to union and rapid bone healing of the forearm Peter M Prokopis, MD, Palm Beach Gardens, FL (n)
pseudarthroses. The osteoinductive characteristics of this bone Arie Chetboun, MD (n)
void filler are based on the unique combination of several
Edward A Athanasian, MD, New York, NY (n)
proteins including Type I collagen, VEGF, TGF²-1, TGF²-2, IGF-1,
BMP-2, BMP-3, and BMP-7. The clinical application of this novel
Andrew J Weiland, MD, New York, NY (n)
bone void filler obviated the need for ancillary surgical treatment Abstract: Fracture-dislocation injuries of the proximal interpha-
associated with donor-site morbidity, such as autogenous iliac langeal (PIP) joint are difficult to treat and often lead to long-
crest or vascularized bone grafting. term pain and stiffness. The purpose of this study was to assess
outcomes of patients treated with a dynamic external fixator
previously not assessed in the literature. This fixator utilizes a
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

POSTERS system of three k-wires and rubber bands that maintains a

reduced joint while allowing for early range of motion. Twelve
patients were treated between 2001 and 2004 for severely
comminuted fracture-dislocation injuries of the PIP joint. Nine
POSTER NO. P224 were available for follow-up at an average of 28 months. Patients
Biomechanical Performance of a Bio-Absorbable were examined for PIP range of motion, grip strength, and pain
Screw for Scaphoid Fracture Fixation on a visual analog scale. Radiographs were obtained at first
follow-up to assess for joint congruency and again at the most
Royston D Wharton, MRCS, Birmingham, United
recent visit to evaluate for arthritis. At follow-up, the average
Kingdom (n) range of motion of the affected PIP joint was -1 to 106 degrees
Jan Herman Kuiper, PhD, Oswestry, Shropshire, (range -5 to 110 degrees). Grip strength, expressed as a
United Kingdom (n) percentage of the unaffected hand, was 93 percent (range 71 to
Cormac P Kelly, Shrewsbury, Shropshire, United Kingdom (n) 125 percent). The average pain scale score was 0.5.
Abstract: To compare the ability of a new composite bio- Complications included 1 pin tract infection and two cases of
absorbable screw and two conventional metal screws to main- small angular deformity. A concentric reduction was achieved in
tain fixation of scaphoid waist-fractures under dynamic loading all. The fixator studied presents a simple method of treating PIP
conditions. Fifteen porcine radial carpi, whose morphology is fracture-dislocation injuries with inexpensive and readily avail-
comparable to that of human scaphoids, were osteotomized at able materials. Outcomes compared favorably with those of
the waist. Specimens were randomized in three groups: those in similar devices studied in the literature. Based on this experience,
group I were fixed with a headed metal screw, in group II with a this fixator represents a satisfactory treatment of these difficult
headless tapered metal screw, and in group III with a bio- injuries.
absorbable composite screw. Each specimen was oriented at 45°
and cyclically loaded using four blocks of 1000 cycles, with peak POSTER NO. P226
loads of 40, 60, 80 and 100 N, respectively. In case of gross Why Plate? Fractures of the Distal Radius:
failure the number of cycles to failure was determined.
Otherwise, permanent displacement and translation (step-off) at
A Unique Approach
the fracture site was measured after each loading block from a Ather Mirza, MD, Smithtown, NY (d – AM Sugical)
standardized high-magnification photograph using image Mary Kate Reinhart, CNP, Smithtown, NY (n)
analysis software (Roman v1.70, Institute of Orthopaedics, Abstract: To assess the radiographic, clinical and functional
Oswestry). Statistical analysis was by ANOVA and tolerance outcome of patients with distal radius fractures treated with a
limits. No gross failure or fracture gap displacement occurred. minimally invasive, non-bridging external fixator. Over a 24
Average translations (step-off) at the fracture site after 4000 month period, 32 patients with distal radius fractures (DRF’s),

514 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 515

extra-articular; displaced, non-displaced and intra-articular; non- screw fixation of scaphoid fractures can result in rapid, reliable
displaced, reducible displaced fractures were treated with a mini- healing, but the surgeon must meticulously adhere to proper tech-
mally invasive cross pin fixation (CPX) system with an nique to reduce the risk of complications.
unobtrusive lightweight non-bridging external fixator /strut. A
removable, custom splint applied 5-7 days post-operatively POSTER NO. P228
allowed early mobilization of the wrist. Radiographic measure- Thumb Flexor Pulley Reconstruction with EPB
ments: radial height, radial inclination, and palmar tilt were
recorded post reduction, post removal of fixation and at 6
Tendon: Technique and Biomechanical Analysis
months post-op. Outcome instrument scores were obtained 5-10 Yury Sless, MD, Stony Brook, NY (n)
days, 3, 6 and 12 months post-op using the DASH and Patient Abraham Baruch, MD, Holon, Israel (n)
Rated Wrist / Hand Evaluation (PRW/HE).Wrist range of motion Gregory Mallo, MD, Stony Brook, NY (n)
(ROM), grip and pinch strengths were measured at specific inter- Fred Serra-Hsu, BS (n)
vals by an Occupational /Certified Hand Therapist. 32 consecu- Abstract: The purpose of this study is to describe a technique for
tive patients were treated with the CPX external non-bridging reconstruction of oblique pulley with distally based extensor
system. 2 patients were excluded: 1 due to non-compliance and pollicis brevis tendon (EPB). We have tested this reconstruction
1 that required synthetic one graft secondary to severe osteo- technique biomechanically and compared it to biomechanical
porosis. The remaining 30 patients, 22 females and 8 males, properties of the intact oblique pulley. The EPB tendon is
mean age 59 (range 28-87) presented as 16 dominant, 12 non- harvested using a transverse incision centered over the first dorsal
dominants, 2 mixed dominance DRF’s. Anatomic reduction was wrist compartment. The EPB tendon is passed around the digit
maintained. Wrist ROM was compared to the contralateral side, volarly to the flexor tendons and extensor pollicis longus tendon
at 12 weeks: dorsiflexion 80%, volarflexion 67 %, pronation and dorsally to the neurovascular bundle and then sutured to
93%, supination 86%, and at 1 year: DF 96%, VF 86%, prona- itself (Fig 1). The biomechanical study design involved dissection
tion 100%, supination 99%, was achieved. At 6 months, mean of 12 preserved cadaver hands. Specimens were dissected and
grip strength was 78% of the contralateral side and 97% at 1 year. mounted on a material testing machine with a specially design jig
Instrument outcomes at 6 months and 1 year revealed mean for phalangeal fixation (Fig 2). The cadaveric oblique pulleys
scores respectively; DASH: 19 and 12, PRWHE: 22 and 12. This were loaded to failure and maximum breaking load and stiffness
study demonstrates that the CPX external non-bridging system is were recorded. The oblique pulleys were then reconstructed with
an effective minimally invasive surgical procedure for stabiliza- distally based EPB tendon using a single loop technique. The
tion of DRF’s. Radial height, palmar tilt and radial inclination are parameters of stiffness and ultimate load applied before failure
maintained. Good clinical and functional results were obtained were measured for the natural oblique pulley as well as for single
as well as comparable DASH and PRWHE outcome scores. loop reconstruction using an EPB tendon. There was no statisti-
cally significant difference in the ultimate load to failure between
POSTER NO. P227 intact oblique pulleys as compared to the single loop reconstruc-
Complications in Percutaneous Screw Fixation of tion using the EPB tendon (Graph 1). There was statistically

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

Scaphoid Fractures significant difference in the stiffness of the intact oblique pulley
as compared to the single loop reconstruction using the EPB
Brandon D Bushnell, MD, Durham, NC (n)
tendon (Graph 2). We found that preserving of distal attachment
Andrew McWilliams, MPH, Chapel Hill, NC (n) of the EPB tendon provides with a reliable bone anchor for
Terry M Messer, MD, Raleigh, NC (n) tendon graft fixation. In all specimens, the length of the tendon
Abstract: With advances in tools and techniques, percutaneous was sufficient to allow for two loop reconstruction which poten-
screw fixation of nondisplaced or minimally-displaced fractures of tially can increase the strength of the newly created pulley.
the scaphoid has gained increasing popularity in recent years as an
alternative to prolonged cast immobilization. Many reports cite POSTER NO. P229
very low complication rates, including no complications in some Role of Type V Collagen in the Pathogenesis of
series. We present our experience with the technique and the
complications we have encountered. A retrospective chart review Dupuytren’s Disease
was performed on the 24 patients of the senior hand surgeon at a Prof Umberto Tarantino, Rome, Italy (n)
Level I trauma center who underwent surgery between October Ilaria Tresoldi, MD, Rome, Italy (n)
2001 and August 2006. All cases involved dorsal percutaneous Paola Trono, PhD, Rome, Italy (n)
screw fixation of nondisplaced or minimally (<1mm) displaced Roberto Bei, MD, Rome, Italy (n)
fractures of the scaphoid waist or proximal pole. Of the 24 Laura Masuelli, MD, Rome, Italy (n)
patients reviewed, 3 lacked adequate follow-up. Twenty of the 21
Marie Agnes Mrozek, PhD, Rome, Italy (n)
remaining patients healed (95%), with one patient requiring revi-
sion surgery for nonunion. Average time until radiographic
Andrea Modesti, Prof, Rome, Italy (n)
healing was 18 weeks overall, 10 weeks for nonsmokers, and 32 Abstract: Abnormal fibroblasts proliferation and collagen depo-
weeks for smokers. Smoking had a statistically significant effect on sition represent the main events in the pathophysiology of
healing (p=0.021). The overall complication rate was 29%, with Dupuytren’s disease, DD, but why this uncontrolled prolifera-
19% major complications and 10% minor complications. Major tion begins and why it continues to the point of debilitating
complications consisted of the one case of nonunion and three flexion contractures remains unknown.The purpose of our study
cases of painful hardware requiring removal. Minor complications was to analyze the extracellular matrix remodelling in DD.
included intraoperative equipment breakage - one case involving Palmar fascia samples were obtained from 20 patients under-
a screw and one case involving a guide wire. Most of these compli- going surgical fasciectomy for DD. Samples of palmar aponeu-
cations occurred early in the learning curve for this procedure, and rosis from 30 patients undergoing hand surgery for carpal tunnel
almost all of them resulted from technical errors. Percutaneous syndrome were used as control tissue. Tissue samples were fixed
and processed for transmission electron microscopy and
immunohistochemistry and incubated with a primary antibody

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
515
PPSE 07:Layout 1 1/12/07 1:41 PM Page 516

against type I, III, IV and V collagens, laminin, fibronectin. good (one each group) fair (three in each group) and poor (4
Ultrastructural analysis of the transitional areas showed the pres- screws, 5 K-wire). Perilunate dislocations and fracture disloca-
ence of a large number of proliferating myofibroblasts with tions are severe injuries. Even at early follow-up intercarpal
increased synthesis activity. A marked extracellular matrix arthritis is commonplace. The results of treatment with screws
remodelling was observed in all areas of palmar aponeurosis are comparable to - and perhaps slightly better than - the results
analyzed. Banded Type I collagen fibrils showed diameter alter- of treatment with Kirschner wires.
ations in the palmar fascia from DD patients compared to
control tissue. Such fibrils were strictly closed to Type V collagen POSTER NO. P231
fibrils that often were isolated and packaged as demonstrated by Determinants of Health Status after Distal Radius
immunoelectron microscopy. Palmar fascia in Dupuytren’s
contracture showed areas with interrupted banded collagen
Fractures
fibrils closely to stromal cells,thus indicating extracellular matrix John S Souer (a – AO Foundation, Wright Medical, Small
degradation. Furthermore, a deposition of glycosaminoglycans, Bone Innovations, Smith and Nephew)
were observed. Immunohistochemical analysis showed an David C Ring, MD, Boston, MA
increased deposition of type I, III and V collagens as well as (a – AO Foundation, Wright Medical, Small Bone
tenascin and fibronectin. Our findings demonstrated that in DD Innovations, Smith and Nephew, b – Wright Medical,
occurred an increased deposition of extracellular matrix compo- c – Hand Innovations, d – Nexa Orthopaedics)
nents, mainly Type III and V collagens along with glycosamino-
Abstract: The purpose of this study was to determine the objec-
glycans. Palmar aponeurosis in DD shows histological features
tive and subjective factors that are most predictive of arm-specific
common with chronic inflammatory or tissue repair processes
health status (as measured by the DASH) and wrist function (as
and with fibroproliferative disorders. Our hypothesis is that Type
measured using physician-based rating systems) after recovery
V collagen produced by myofibroblasts leads to the disarrange-
from a fracture of the distal radius fractures. Eighty-four patients
ment of Type I collagen organization during extracellular matrix
were evaluated a minimum of six months after an unstable distal
remodelling in DD, with subsequent alteration of mechanical
radius fracture using two physician-based evaluation instru-
forces acting on aponeurotical bundles and therefore appear-
ments (Mayo Wrist Score and the Gartland and Werley Score)
ance of the typical Dupuytren’s contracture.
and an upper extremity specific health status questionnaire
POSTER NO. P230 (Disabilities of the Arm, Shoulder and Hand). The physician-
based scoring systems showed moderate correlation (r=-
Perilunate Fracture-Dislocations: Comparison of 0.32,P=0.003) with each other and with DASH scores (r = 0.41;
Temporary Screw vs. Kirschner Wire Fixation r =-0.32; p<0.001). The results of multiple linear regression were
John S Souer (a – AO Foundation, Wright Medical, as follows (percent variability with the best fit model/percent
variability explained by pain alone): Mayo score—29% (grip
Small Bone Innovations, Smith and Nephew)
and pain)/ 22% grip alone; Gartland and Werley: 49% (pain,
Marijn Rutgers, MD, Amsterdam, Netherlands
flexion arc, radiocarpal arthritis, and duration of follow-up)/
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

(a – AO Foundation, Wright Medical, Small Bone 28% pain alone; DASH: 51% (pain, forearm arc and fracture
Innovations, Smith and Nephew) type )/ 43% pain alone. Pain dominates the patient’s perception
Jesse B Jupiter, MD, Weston, MA of function after recovery from a distal radius fracture as meas-
(a – AO Foundation, Wright Medical, Small Bone ured by the DASH score. Physician-based systems were also
Innovations, Smith and Nephew b – Wright Medical, strongly determined by pain as well as grip strength (also a
c – Hand Innovations, d – Nexa Orthopaedics) reflection of pain and motivation). Because the perception of
David C Ring, MD, Boston, MA (a – AO Foundation, pain is strongly influenced by psychosocial factors, both patient-
based and physician-based measures of wrist function after frac-
Wright Medical, Small Bone Innovations, Smith and
ture of the distal radius may reflect illness behavior more than
Nephew, b – Wright Medical, c – Hand Innovations,
objective pathology.
d – Nexa Orthopaedics)
Abstract: We analyzed whether temporary screw fixation of POSTER NO. P232
perilunate fracture dislocations would decrease complications
The Intact and Proximal Carpectomy Wrist:
and improve final wrist motion when compared to Kirschner
wire fixation. Eighteen patients with operatively treated perilu- A Comparison of Contact Biomechanics
nate injuries (9 treated with buried screws and 9 with Kirschner Peter Tang, MD, Pittsburgh, PA (n)
wires) were evaluated an average of 44 months (range 7 to 115 Jean Gauvin, PhD (n)
months) after injury. Complications included 1 deep infection Mituri Muriuki, PhD (n)
of the wrist (screw fixation), 2 pin track infections, 2 scaphoid Jamie Pfaeffle, Pittsburgh, PA (n)
nonunions (screw fixation) and 2 loss of reduction (K-wire fixa-
Robert Kaufmann, MD, Pittsburgh, PA (n)
tion) treated with repeat surgery. Four patients (two in each
cohort) had wrist arthrodesis and were considered poor results.
Joseph E Imbriglia, MD, Wexford, PA (n)
Among the 14 remaining patients the final flexion arc was 97 Robert Joseph Goitz, MD, Pittsburgh, PA (n)
degrees (range, 55 to 135) for patients treated with screw fixation Abstract: The purpose of this study was to evaluate average pres-
compared to 73 degrees (range, 50 to 100) for patients treated sure, contact area, and kinematics between the intact and prox-
with kirschner wires. Seven patients (2 screws, 5 k-wires) had imal row carpectomy (PRC) wrist. Six fresh-frozen cadaveric
signs of midcarpal arthritis grade 2 or 3 according to the criteria forearms had UltraSuperlow Fuji film inserted in the radiocarpal
of Knirk and Jupiter, but none had more than mild radiocarpal joint and a total force of 200 N was applied. The wrists then
arthritis. The mean grip strength was 74% (screw fixation) and underwent PRC and the experiment was repeated with
67% (K-wire) of the uninjured arm. According to the Mayo SuperLow and Low film. The film was analyzed for average pres-
Modified Wrist Score the functional result was excellent (screw), sure, area and location of contact. Multivariable ANOVA with

516 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 517

multiple contrast testing was performed. In the intact wrist, there based injury presentation and pre-reduction radiographs.
was significant decrease in scaphoid contact area (57 -59%) in Twenty-four patients that underwent release of an acute carpal
flexion. Lunate pressure significantly increases in extension and tunnel syndrome in association with ORIF of a distal radius frac-
flexion. When comparing scaphoid and lunate contact, there ture were identified. Each was matched with one control patient
was no significant difference in pressure in all positions but there of the same gender, similar age (+/- 4 years), and similar injury
was a trend for greater scaphoid pressure (1.2 -1.8 x’s). Scaphoid mechanism that had ORIF of a distal radius fracture but no
contact area is 1.5 x’s greater than lunate area in extension and release. Radiographic measurements of deformity included ulnar
neutral. Most importantly after PRC, average pressure signifi- variance, radial inclination, palmar tilt, translational loss of frac-
cantly increases 3.2- 4.0 x’s, while contact area significantly ture apposition (as percent of proximal fragment bone diam-
decreases by 35 to 55%. Few studies have evaluated the biome- eter). Open wounds, associated wrist injuries, ipsilateral upper
chanics after PRC. Our study shows that contact pressure extremity injuries, and multitrauma were also evaluated. The
increases and area decreases after PRC. Furthermore, this study overall prevalence of acute carpal tunnel syndrome was 4.2%
also delineates scaphoid and lunate contact in the intact wrist. (24 of 560 patients). Among patient-related factors no signifi-
This research will help better understand the biomechanics of cant differences were found. Among radiographic parameters
the PRC. Our next endeavor is to evaluate ‘total area’ of contact there was a nearly significant trend suggesting that initial dorsal
between the intact and PRC wrist in attempts to understand the translation can predict acute carpal tunnel syndrome (Students
PRC’s relatively good clinical success despite its distinct biome- t-test, p=0.065). Our analysis did not find any statistically signif-
chanical disadvantage. icant predictors of acute carpal tunnel syndrome in association
with fracture of the distal radius with the numbers available. It is
POSTER NO. P233 difficult to predict who—among patients at known risk by age,
Correlations Between ASSH Annual Meeting gender and injury mechanismwill develop it. The near-signifi-
cant finding that dorsal translation of the fracture is associated
Presentations and Final Publications with increased risk may be helpful, but routine prophylactic
Rachel Y Goldstein, BA, New York, NY (n) carpal tunnel release cannot be supported by these results.
George D Gantsoudes, MD, New York, NY (n)
Steve K Lee, MD, New York, NY (n) POSTER NO. P235
Michael Hausman, MD, New York, NY (n) The Value of Routine Use of Radiographs for Dorsal
Abstract: This study examined the correlation between American Wrist Ganglions
Society for Surgery of the Hand Annual Meeting presentations
Derek R Johnson, MD, Grand Rapdis, MI (n)
and final publications. Presentations from ASSH annual meet-
ings 1998-2002 were included in this study. A Medline internet Timothy W Powers, MD, Holland, MI (n)
search was conducted of the presentations. Resulting abstracts Julian E Kuz, MD, Grand Rapids, MI (n)
were examined for similarities in title, methodology, results, and Abstract: Dorsal wrist ganglions are common diagnoses for
authorship. Authors whose presentations had not been Orthopaedic Surgeons with a referral incidence of 55 per

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

published were sent a questionnaire via email, assessing current 100,000, or 165,000 per year. Despite their characteristic appear-
publication status and reasons for non-publication. There were ance and location, it is common to include routine wrist radi-
a total of 395 presentations at the 1998-2002 ASSH annual ographs in the initial evaluation. It is our objective to evaluate
meetings; 229 were published by November 2005. Many of the cost and benefit of this practice. In a community based hand
papers published underwent changes before publication. 63.3 practice, a retrospective chart review of 102 patients with
percent changed authorship in some way; 35.8 percent of papers confirmed diagnosis of dorsal wrist ganglion was performed.
adjusted the number of subjects included. 8.5 percent had Data points collected were age, gender, side of ganglia, hand of
changed their conclusions. Surveys were emailed to 162 authors dominance, history of trauma, history of malignancy, range of
whose papers were not found through our literature search. Of motion, and radiographic and pathologic results. One hundred
survey respondents, 24.7 percent of authors stated their study two patients had confirmed dorsal wrist ganglion on aspiration
had already been published. 29.2 percent of survey respondents or excision. Of those, 13 (12.7%) had positive radiographic
reported that their study had been submitted for publication but findings, of which seven had previously known findings. Of the
rejected at an average number of 1.31 journals. 36.0 percent of remaining six patients with new radiographic findings, none had
survey respondents reported their study had never been their clinical management altered secondary to the findings.
submitted for publication, most commonly secondary to insuf- Despite the ease of diagnosis, many surgeons use routine wrist
ficient time to prepare for publication (33.3 percent). The publi- radiographs as a screening exam in dorsal wrist ganglions. This
cation rate of 57.2 percent is higher than previously reported. We practice in 102 patients failed to alter the treatment for any
demonstrated that 8.5 percent of papers changed their conclu- patient. With cost per radiograph ranging from $28.94
sions prior to publication. We found that the largest proportion (Medicare reimbursement) to $72.00 (our institution fees) the
of survey respondents had never submitted their paper for publi- cost per positive radiographic finding ranged from $227.07 to
cation secondary to insufficient time. $564.92, with a total cost of $2951.88 to $7344. With an inci-
dence of 165,000 per year, the total cost of this practice would
POSTER NO. P234 range from $4,775,000 to $11,880,000. The clinician should be
Predictors of Acute Carpal Tunnel Syndrome aware of the significant cost and low odds of altering their treat-
ment with this practice.
Associated with Fracture of the Distal Radius
George S Dyer, MD, Cambridge, MA (n)
David C Ring, MD, Boston, MA (a – AO Foundation)
Abstract: High-energy displaced distal radius fractures are at risk
for acute carpal tunnel syndrome. We performed a case-control
study to determine risk factors for acute carpal tunnel syndrome

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
517
PPSE 07:Layout 1 1/12/07 1:41 PM Page 518

POSTER NO. P236 POSTER NO. P238

A Comparison of Fixation for Fractures of the Genetic Expression in the Healing Murine Tendon
Distal Ulna Gwynne Bragdon, MD, Rochester, NY (n)
Mark M Kuper, DO, Lubbock, TX (n) Alayna Loiselle, BS (n)
Eric Randall Brock, MD, Lubbock, TX (n) Regis J O’Keefe, MD, Rochester, NY (n)
Sachin Kholamkar, MS (n) E M Sanchez, PhD (n)
Das Kaushik, BS (n) David J Mitten, MD, Rochester, NY (n)
Richard Pfeiffer, MD, Lubbock, TX (n) Justin Jacobson, MD, Rochester, NY (n)
Javad Hashemi, PhD (n) Hani A Awad, Cincinnati, OH (n)
Abstract: Fractures of the distal ulna occurring within 3 cm of the Zenia Cortes, MD, Long Beach, CA (n)
articular surface are a challenge to stabilize. With standard plates, Abstract: Tendon injury results in abundant scar formation that
distal purchase is limited to two cortices. As such,a popular reduces joint range of motion. The murine FDL tendon was
method by which to treat these complex fractures is with a mini isolated, transected, and repaired to evaluate the molecular,
modular blade plate. A valuable alternative to the mini blade cellular, and biomechanical events involved in repair. Mice were
plate is the low profile one-third tubular locking plate. By sacrificed at 3, 7, 10, 14, 21, 28, 35, and 49 days post repair and
placing a locked screw into the distal fragment, the fixed-angled tendons evaluated for histology, gene expression, and biome-
device can be secured to the proximal fragment in a similar chanical testing. Histology demonstrates stem cell proliferation
fashion as the mini blade plate. The purpose of this study was to by day 7 originating in the synovium. By day 14, a callus of stem
compare the biomechanics of the one-third tubular locking cells bridges the injury site and begins to invade and replace the
plate versus the mini blade plate when used to treat fractures adjacent normal tendon. On day 21, the tendon has healed with
within 3 cm of the articular surface of the distal ulna. Open a disorganized fibroblastic tissue that progressively remodels
reduction internal fixation with a locking one-third tubular plate with organization of longitudinal collagen fibers by day 35.
versus a 2.7mm modular hand mini-blade plate of an oblique Gene expression demonstrates an organized sequence of
distal ulna fracture within three cm of the articular surface were collagen deposition and remodeling. Col3 peaks rapidly and
compared using ABAQUS/CAE Version 6.5-1 Finite Element early where as Col1 peaks at day 14 and illustrates a more
Analysis Software. Results indicated that the modular blade plate sustained increase in expression. The gene expression of matrix
failed at much lower physiologic loads than the locking one- metalloproteinases were also examined. MMP-2 and MMP-14
third tubular plate. We conclude that the low profile one-third reached peak expression on day 21 during the maximum phase
tubular locking plate offers a stronger construct in these difficult of remodeling. Scleraxis , a tendon specific gene, increases from
fractures and that its utility in fractures within 3cm of the distal day 3 to 7 and remains elevated through day 35. Tensile strength
articular surface should be considered. and load to maximal failure increase over time, but the adhesion
coefficient of the repaired tendon remains elevated. The experi-
POSTER NO. P237 ments define molecular, cellular, and biomechanical events
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

The “Blind Spot” in Scaphoid Fixation during tendon repair and demonstrate exuberant formation of
adhesive scar tissue and failure to produce normal tendon tissue.
T Michelle Gale, MD, Natick, MA (n) This model provides an important tool to understand and
Lauren Grossman, BA (n) potentially improve tendon repair.
Charles Cassidy, MD, Natick, MA (n)
Abstract: Screw penetration is a concern when fixing scaphoid POSTER NO. P239
fractures percutaneously. We propose that the scaphoid has a Proprioception of the Hand and Wrist Following
blind spot where screw penetration may easily be missed using
conventional x-rays. Randomly selected axial Computed Posterior Interosseous Sensory Neurectomy
Tomography scans of 20 normal wrists were used to calculate the William H Seitz Jr, MD, Cleveland, OH (n)
slope of the radial aspect of the scaphoid, the volume where an Monica Van Niel, OTR/L (n)
improperly placed screw could potentially appear to be within Abstract: Resection of the sensory branch of the posterior
the bone on standard radiographs, and the surface area of the interosseous nerve in the floor of the fourth extensor compart-
radial aspect of the scaphoid to determine the area of the bone ment to denervate the wrist capsule. This has been utilized as a
where the screw might penetrate into the radiocarpal joint. A primary as well as adjunctive procedure in the management of a
consistent slope to the scaphoid was found averaging 47 degrees variety of pathologic conditions of the wrist joint. The purpose
at the proximal pole and 54 degrees at the distal pole. The of the procedure is to provide added analgesia in arthritic and
volume where an improperly positioned screw could not be post-reconstructive joints through ablation of sensory fibers
visualized by a standard radiograph averaged 599.97 mm3. The transmitting pain perception. Little information exists, however,
surface area of the bone that could potentially be penetrated by regarding the proprioceptive function of the posterior
the screw averaged 305.82 mm2. In cadaveric studies, a 40 interosseous nerve and whether resection of this nerve results in
degree hyperpronation view confirmed malposition of the alteration of proprioception to any degree. Twenty-six patients
screw. The potential area whereby a malpositioned screw may be who underwent posterior interosseous sensory neurectomy as
missed is quite large. Our results show that proper screw place- part of a reconstructive wrist procedure were evaluated by a
ment can be confirmed intraoperatively by use of a 40 degree battery of proprioceptive test to determine position of the hand
hyperpronation view. and wrist in space at multiple angles. The contralateral (nonop-
erated wrist) was used as a control. Additionally, both wrists of
25 healthy volunteer individuals who had had no surgery were
examined as additional controls and the results compared to
surgical patients. No statistically significant loss of propriocep-
tive ability was noted between posterior interosseous sensory

518 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 519

neurectomy wrists and the contralateral control rests. Similarly the scaphoid and metacarpal with maintenance of
no statistically significant loss of proprioception was noted scaphometacarpal height index of 0.85 or less are consistent
between surgical patients and volunteer controls. Comparison of with satisfactory functional outcomes.
dominant versus nondominant wrists demonstrated no statis-
tical significant difference between surgical and nonoperative POSTER NO. P241
side and between surgical and volunteer control patients. Long-Term Outcomes of Dorsal Intercarpal
Interestingly, neither the treatment nor control populations were
very accurate in approximating angle objectives (7-15° discrep-
Ligament Capsulodesis for Chronic Scapholunate
ancy) . Postoperative patients were not consistently further from Dissociation
the objects than the control patients. This study demonstrates Varun K Gajendran, MS, Roseville, CA (n)
that there is no significant loss of proprioceptive ability in Brett Peterson, MD, Loomis, CA (n)
patients who have undergone a posterior interosseous sensory Robert Morris Szabo, MD, MPH, Sacramento, CA (n)
neurectomy when compared to either the nonoperative side nor
Abstract: Chronic scapholunate dissociation is a common cause
to a population of control patients. Interestingly, this study also
of symptomatic wrist instability. In an attempt to restore normal
demonstrated that native proprioception does not appear to be
carpal mechanics and prevent arthrosis, we developed and tested
extremely accurate at the wrist level in the general population.
biomechanically the dorsal intercarpal ligament capsulodesis
POSTER NO. P240 (DILC). Previously, we reported good early clinical results of this
procedure. Here, we report the functional and radiographic
Outcome of Thumb CMC Arthroplasty - Correlation outcome of these patients at intermediate and long term follow-
of Radiographic and Clinical Parameters up. After IRB approval, records of patients undergoing DILC for
William H Seitz Jr, MD, Cleveland, OH (n) chronic (>6 weeks) scapholunate dissociation were reviewed.
Only patients with follow-up of >60 months were included.
Hideaki Matsuoka, MD, Cleveland, OH (n)
Patients were evaluated by physical exam, radiographs, and vali-
Abstract: Many techniques exist for performance of
dated outcome instruments. Thirteen patients (average age 41
carpometacarpal joint fascial interposition arthroplasty. They
years at surgery) met inclusion criteria. Eleven were available for
vary from simple resection and tendon interposition to ligament
follow-up. After an average of 97 months, examination revealed
reconstruction and metacarpal suspension. This paper seeks to
an average of 57 degrees of wrist extension and 49 degrees of
assess the results following CMC arthroplasty by evaluating the
wrist flexion. Radial and ulnar deviation averaged 19 degrees and
ability to maintain scaphometacarpal height and axial align-
29 degrees respectively. DASH, SF-12, and Mayo Wrist scores
ment in the postoperative period and comparing those results
averaged 23.8, 77.5, and 72.3 respectively. Radiographs revealed
with generation of pinch strength. A jig was developed to obtain
an average scapholunate angle of 65 degrees and a gap of 4.2mm.
standardized true PA radiographs of the thumb at rest and
Nine of 13 patients exhibited early signs of SLAC wrist, and one
during maximal pinch. X-rays obtained within this jig were then
developed Stage IV arthritis. All radiographic and range of
analyzed posoperatively at six weeks, twelve weeks and one year
motion parameters deteriorated to near pre-operative values.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

for maintenance of both scaphometacarpal height index and
Interestingly, however, grip strength was increased significantly at
axial alignment. This was measured as a percentage of the entire
long-term follow-up compared to pre-operative values. Although
length of the distance from the distal articular surface of the
the DILC appears to show promise in the short term following
scaphoid to the metacarpal head divided by the length of the
surgery in reversing the effects of chronic scapholunate dissocia-
metacarpal shaft at rest, and during performance of maximal tip-
tion, it does not appear to prevent development of a SLAC wrist
to-tip pinch. The same x-rays were evaluated for lateral subluxa-
pattern upon long-term follow-up examination. The significant
tion by evaluation of co-axial alignment of the scaphoid and
improvement in grip strength and patient satisfaction observed in
metacarpal. Fifty-three patients having undergone CMC arthro-
the long-term despite radiographic deterioration might suggest
plasty were evaluated. A control group of normal (nonarthritic)
that there is still a role for this procedure in selected patients.
hands were evaluated for a range of normal scaphometacarpal
height index (a range of .72 to .81 was encountered with a mean POSTER NO. ORS 4
of .78). Postoperative patients demonstrated a mean of .82 at six
weeks, .84 at twelve weeks which persisted at one year following Repetitive Motion Leads to Declines in Reach Motor
surgery. Co-axial scaphometacarpal alignment (>1.0 mm) was Performance in a Rat Model
seen at rest in 88% of controls while 12% of patients demon- Ann E. Barr, DPT, PhD, Philadelphia, PA
strated a lateral displacement of 1 mm or more at rest. All (a – Temple University)
patients demonstrated at least 1 mm and up to 3 mm of lateral
David M. Kietrys, PT, MS, OCS
displacement on maximum pinch. Control patients demon-
strated 1-1.5 mm with maximal pinch. A direct correlation was
(a – NIH/NIAMS, CDC, NIOSH)
found between scaphometacarpal height index and pinch Allison M.Brown, PT, MA
power. Those patients with a scaphometacarpal height index of (a – NIH/NIAMS, CDC, NIOSH)
0.85 or less at rest felt they had normal functional use of their Marcus Handy, BS (a – NIH/NIAMS, CDC, NIOSH)
hands. On objective tests, they demonstrated between 70 and Mamta Amin, BS (a – NIH/NIAMS, CDC, NIOSH)
95% (mean 86%) pinch power of their contralateral (unin- Mary F. Barbe, PhD (a – NIH/NIAMS, CDC, NIOSH)
volved) hand. The CMC resection/interposition arthroplasty is a Introduction: Repetitive and forceful movements contribute to
well accepted and effective means of treating CMC arthritis. work-related musculoskeletal disorders. The purpose of this study
Performance of this procedure is intended to relieve pain and was to quantify exposure-dependent reach movement pattern
improve function. Most surgical procedures do relieve pain. This changes of the forelimb in a rat model of repetitive motion injury.
study demonstrates that maintenance of co-axial alignment of Methods: Forty-nine Sprague-Dawley rats learned to perform a
reaching task at a low repetition-low force (LRLF), high repeti-
tion-low force (HRLF), or high repetition-high force (HRHF)

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
519
PPSE 07:Layout 1 1/12/07 1:41 PM Page 520

level at 2 hrs/day for 6 weeks. Reach rate and duration of task SCIENTIFIC EXHIBIT NO. SE46
participation were recorded. Video motion analysis was used to Surgical Decision Making for Unstable Fractures of
determine number of movement reversals during grasp phase,
total reach time, and grasp time. Repeated measures ANOVA was the Distal Radius: The Temple University Algorithm
used to compare reach rate and task duration at weeks 3 and 6 to Joseph Thoder, MD, Philadelphia, PA (n)
week 1 within groups; and to compare reach movement reversals, Matthew Reish, MD, Long Beach, CA (n)
total reach time, and grasp time at weeks 1 and 6 between groups. Kristofer S Matullo, MD, Roslyn, PA (n)
There were significant declines in reach rate and duration in both Pekka A Mooar, MD, Philadelphia, PA (n)
the HRLF and HRHF groups. Forelimb movement reversals, total
Treatment of the unstable distal radius fracture requires a sound
reach time and grasp time increased from week 1 to week 6 in the
understanding of fracture patterns, knowledge of distal radius
HRHF group only. Conclusions: Our results show the emergence
fixation devices, and the ability to apply meticulous surgical
of uncoordinated movement patterns in the early development
technique. This scientific exhibit presents a complete and
of repetitive motion injury that is dose-dependent. The increase
concise algorithm for the treatment of this injury. Treatment
in fore-aft submovements contributes to a longer grasp phase.
selection focuses on fracture stability, acceptable parameters for
The reduction in reach rate and task duration in the HRHF group
closed management and stresses the need for devices that
is countered by increased submovements, thereby maintaining
address specific fracture personalities. This algorithm addresses
risk exposure at a relatively high level of repetition and force.
the key features of fracture geometry and instability, and matches
Such disordered movement patterns may further increase risk for
appropriate fixation approaches. Knowledge of distal radius
repetitive motion disorders.
biomechanics and fracture classification is key to applying the
concepts of the algorithm. The algorithm includes: volar shear,
volar ulnar corner and dorsal ulnar corner, dorsal comminution,
SCIENTIFIC EXHIBITS articular involvement, volar ulnar fragment, dorsal ulnar frag-
ment, styloid rotational deformities and volar cortex reducibility.
The integrity of the volar cortex calcar of the wrist is the key
SCIENTIFIC EXHIBIT NO. SE45 element in decision making. Each unstable fracture has its own
Biomechanical Properties of Fixed-Angle Volar geometry, which dictates its personality and treatment.
Restoration of volar cortex integrity establishes longitudinal
Radius Plates Under Dynamic Loading stability, radial length and volar tilt. Critical instability features
Paul Nassab, MD, Kansas City, MO (n) include dorsal comminution, articular involvement, and styloid
Paul D Postak, BSc, Cleveland, OH (n) rotational deformities. This algorithm allows for the approach
Jeffrey N Lawton, MD, Cleveland, OH (n) and fixation type to be matched to the fracture configuration.
Kraig M Burgess, DO, Phoenix, AZ (n) Three surgical approaches to the distal radius (volar, dorsal and
Peter J Evans, MD, Cleveland, OH (n) radial) provide exposure to the entire distal radius and are
reviewed by video presentation. This exhibit presents a concise
PAPERS, POSTERS & SCIENTIFIC EXHIBITS HAND/WRIST

William H Seitz, Jr, MD, Cleveland, OH (e – Stryker, SBi)

algorithm to identify fracture patterns, recognize radiographic
A Seth Greenwald, DPhil Oxon, Cleveland, OH
subtleties and recommends appropriate fixation strategies for
(a – Acumed, Hand Innovations, SBi, Stryker, Synthes,
the unstable distal radius fracture.
Wright Medical, Zimmer)
Open fixation of distal radius fractures has undergone a para-
digm shift. Fixed-angle designs have allowed volar fixation of
dorsally comminuted fractures. Studies have compared the
biomechanical properties of dorsal and volar constructs under
static conditions. The purpose of this study was to compare the
biomechanical properties of eight different fixed-angle volar plate
designs under cyclic loading which simulates postoperative wrist
motion. Seven plates of each design (Acumed, Hand
Innovations, Synthes Articular, Synthes Extra-articular,
Avanta/SBI, Stryker, Wright Medical, Zimmer) were fixed to a
corticocancellous composite sawbone. A 1cm dorsal wedge
osteotomy was made. Each construct was loaded (MTS) for 2000
cycles at 100, 200 and 300 N, respectively, and then to failure at
1 N/s. Distal locking screws were visually inspected for loosening.
Load-deformation curves were determined. No screw loosening
was observed. Stiffness increased significantly after the initial 100
N cyclic testing. The Zimmer, Hand Innovations and Acumed
plates had the highest yield points which were significantly
higher than several of the other designs (p<0.05). The lowest
average yield point observed for any design was 967 N. Although
significant differences were found, all brands of plates failed at
higher loads than would be experienced during normal digital
motion and hand function. Early active motion should not
compromise the integrity of any of these plates during the repair
phase of fracture healing. Fracture pattern and screw configura-
tion may be more important than biomechanical differences
between these plates when selecting a plate for fracture fixation.

520 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 521

P E D I AT R I C S
PAPERS ative management of patients with sickle cell anemia can be
complex. In addition, there is tremendous variance of manage-
ment for post-surgical patients. There is no consensus for
absolute guidelines for appropriate treatment of these patients
PAPER NO. 271 according to the latest available Cochrane Collaboration review.
Perioperative Management of Patients with Sickle The investigators believe that the use of fresh frozen plasma and
Cell Disease Undergoing Orthopedic Procedures preoperative optimization of hemoglobin levels obviates against
the necessary use of ancillary oxygen and other blood products
Michael A Mont, MD, Baltimore, MD (n)
and may benefit these difficult to manage patients.
Caterina P Minniti, MD (n)
German A Marulanda, MD, Baltimore, MD (n) PAPER NO. 272
Abstract: According to the Center for Disease Control, one in Congenital Osseous Anomalies of Upper Cervical
twelve African-Americans is a carrier of the sickle cell trait in the
United States and sickle cell disease (SCD) is one of the most Spine in Children: A Double-Cohort Study
common inherited disorders in the world. Patients with SCD are Harish Sadanand Hosalkar, MD, Philadelphia, PA (n)
more likely to require surgical procedures (such as cholecystec- Wudbhav N Sankar, MD, Philadelphia, PA (n)
tomies and total hip arthroplasties) when compared to the Brian Philip Donald Wills, MD, Fitchburg, WI (n)
general population. In addition to the increased frequency of John P Dormans, MD, Philadelphia, PA (n)
surgical procedures, patients with SCD are at risk for multiple Denis S Drummond, MD, Philadelphia, PA (n)
peri-operative complications (such as vaso-occlusive crisis,
Abstract: The embryology, anatomy, and biomechanics of the
hemolytic anemia, and multi-organ failure). Avascular necrosis
upper cervical spine are unique. Children with congenital
of the femoral head occurs in 10% of adolescents and young
osseous anomalies in this region may be at increased risk for
adults with SCD and many will eventually require a total hip
subsequent neurological compromise likely from instability
replacement. The procedures may involve blood loss that can be
and/or cord encroachment. We performed a double-cohort
in excess of one liter. Patients with SCD often have coagulation
study evaluating congenital osseous anomalies of the upper
abnormalities on pre-op screening, with PT most frequently
cervical spine in children and have attempted to outline the risk
elevated. The purpose of this report was to review a multi-center
of possible neurological compromise. The medical records and
experience with the perioperative management of patients with
imaging modalities of all consecutive children with osseous
SCD. Between January 1, 2000 and December 1, 2005, 31
anomalies of the upper cervical spine managed between 1988
orthopaedic procedures related to avascular necrosis were
and 2003 were reviewed. Patients were divided in to two cohorts;

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

performed on 23 patients with SCD. There were 12 women and
syndromic and non-syndromic. Clinical presentation and
11 men with a mean age of 18 years (range, 13 to 40 years).
imaging features were reviewed and all osseous, canal, lower
Surgical procedures ranged from various types of bone-
CNS and cord anomalies including canal encroachment,
preserving techniques such as bone grafting (n=9), core decom-
stenosis and instability were characterized in both groups.
pressions (n=9), and iliopsoas release with hip distraction (n=4)
Statistical analysis was performed. Sixty-eight children were
to total hip arthroplasties (n =9). Twol different protocols for
identified. Twenty-eight patients had an underlying syndrome
perioperative management were utilized and compared. In
and 40 did not. We recorded a spectrum of anomalies, including
group A, fifteen patients had their hemoglobin preoperatively
hypoplasia of C1, occipitalization of C1, hypoplastic dens, os
optimized to between 9 and 10 grams per deciliter and hemo-
odontoideum, C2-3 fusion, basilar invagination, and Chiari
globin S (HbS) lowered to less than 30%. This was achieved
malformations in all patients. There were 229 anomalies noted
either with exchange transfusion or with a series of Packed Red
in both groups (average 3.4 per patient). Three or more anom-
blood cell transfusions over 6 to 8 weeks. If the prothrombin
alies were noted in 79% of cases. Between syndromic and non-
time was elevated and Factor VII was less than 30%, patients
syndromic patients, there was no significant difference in
were given fresh frozen plasma immediately before the proce-
number of anomalies (p=0.79) or in the frequency of any
dure to minimize intra-operative blood loss, and to maintain the
specific anomaly (p>0.20 for all). There were varied clinical
eventual hemoglobin level over 7 grams per deciliter. In Group
presentations; neurological changes (21 cases), torticollis (21
B, eight patients had preoperative stabilization of the hematocrit
cases), neck-pain (16 cases), and multiple complaints (23 cases).
to a minimum of 30% and were only given blood products if
Ten children were diagnosed following injury, eight incidentally
excessive intra-operative bleeding occurred. Criteria for transfu-
and 20 (syndromic) were noted during screening. Twenty
sion were a hematocrit under 21%, or any episode of hypoten-
patients had isolated column instability, 16 had isolated cord
sion, refractive acidosis, or post-operative painful crisis. An
encroachment, and 21 had a combination of both. Forty-four
analysis of orthopaedic or medical complications was
(65%) required surgical intervention (decompression and/or
performed. There were no blood-related or other perioperative
fusion) in their management We noted no significant differences
complications noted in the patients that received fresh frozen
in the frequency or presentation of anomalies between the
plasma prior to surgery (Group A). Group B patients also did
syndromic and non-syndromic cohorts. Surgery is frequently
clinically well, but in 3 cases required multiple intra- and post-
required to manage these difficult problems in both groups.
operative transfusions. One patient eventually required 3 units
Multiple anomalies are common in both cohorts (mean 3.4).
of blood after a perioperative blood loss of 1,000 mls. This
We therefore recommend thorough evaluation and advanced
patient is doing clinically well at latest follow-up. Two other
imaging of the upper cervical spine in all cases to look for asso-
patients required post-operative supplemental oxygen. No other
ciated anomalies and further define the canal encroachment
orthopaedic or surgical complications were noted. The perioper-
including potential for neurologic compromise.

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
521
PPSE 07:Layout 1 1/12/07 1:41 PM Page 522

PAPER NO. 273 Down’s syndrome (2 patients), posttraumatic instability (1

Advanced Imaging of Occipitalization in Children patient), Morquio’s syndrome (1 patient) and cerebral palsy (1
patient). When posterior elements were intact, a modified
Purushottam Arjun Gholve, MD, New York, NY (n) Brooks wiring was used in conjunction; 3 patients were immo-
Harish Sadanand Hosalkar, MD, Philadelphia, PA (n) bilized in halo-vests, the 8 others were protected in a hard collar
Eric T Ricchetti, MD, Philadelphia, PA (n) until union was achieved. All children achieved arthrodesis at 3
Avrum Pollock, MD, FRCPC (n) months postoperatively. The average blood loss was 90 cc (range
John P Dormans, MD, Philadelphia, PA (n) 50-250) and the average length of stay was 4.7 days in the
Denis S Drummond, MD, Philadelphia, PA (n) hospital. Nine patients had successful placement of two screws.
Abstract: No previous studies address morphologic patterns of Two patients were amenable only to unilateral screw placement:
occipitalization with their implications in children. This study is one had an intraoperative vertebral artery injury with no clinical
the single largest series of occipitalization in children with sequela and one patient had intraoperative diminution of tran-
advanced imaging and clinical characteristics. Retrospective scranial motor evoked potentials with return to baseline after
review of patient charts and imaging studies of all consecutive screw removal. One patient required later extension of the
children diagnosed with occipitalization. Advanced imaging arthrodesis for junctional instability at C2-3. There were no
(two-dimensional sagittal and coronal reformatted CT recon- permanent neurologic deficits. The minor complications related
structions and/or MRI) categorized occipitalization in four to surgery were superficial wound infections (2 patients), tran-
morphologic patterns according to the anatomic site of fusion sient swallowing difficulty (1 patient), extension of the fusion to
(Zone 1 to 3 and combination of zones). Images were also C3 (1 patient), and junctional kyphosis (1 patient)
reviewed for evidence of instability and other anomalies of cran- Transarticular screw fixation can be successfully performed in
iovertebral junction. Thirty patients were identified with occipi- children as young as 4 years of age for a variety of pathology and
talization. There were 24 boys and six girls with mean age of 6.5 achieve a high rate of union. Preoperative planning with multi-
years (range, 0.5 to 15 years). Morphologic categorization was as planar, fine-cut CT scans, proper reduction of the instability,
follows: Zone 1, fused anterior arch- 6 cases, Zone 2, fused lateral meticulous attention to anatomic variations and intraoperative
masses-5 cases, Zone 3, fused posterior arch- 4 cases, and combi- fluoroscopic guidance and can improve outcomes and safety.
nation of fused zones-15 cases. 17/30 (57%) patients had
atlantoaxial instability and eight of these had associated C 2-3
PAPER NO. 275
fusion. 11/30 (37%) patients had canal encroachment of which Maturity Assessment and Curve Progression in
5/30 (17%) had myelopathy. 79% of C 2-3 fusion and 73% of Girls with Idiopathic Scoliosis
basilar invagination had occipitalization in zones 1 and/or 2 but
James O Sanders, MD, Erie, PA
this was not statistically significantly correlated. The highest inci-
dence of canal encroachment (63%) was noted in zone 2. (a – Scoliosis Research Society)
Occipitalization is associated with pathologies that encroach on Richard H Browne, PhD, Dallas, TX
the space available for cord or brainstem such as atlantoaxial (a – Scoliosis Research Society)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

instability, canal stenosis, basilar invagination, and Chiari Sharon J McConnell, MS (a – Scoliosis Research Society)
malformation. Risk for developing atlantoaxial instability is Susan Margraf (a – Scoliosis Research Society)
high particularly when there is associated congenital C 2-3 Timothy E Cooney, Erie, PA (a – Scoliosis Research Society)
fusion. Our study noted a higher incidence of basilar invagina- David N Finegold, MD (a – Scoliosis Research Society)
tion, canal encroachment and C 2-3 fusion in occipitalization of Abstract: Scoliosis progression during adolescence is related to
zones 1 and/or 2. Two-dimensional sagittal and coronal refor- patient maturity. Maturity is reflected in chronological age,
matted CT reconstructions and/or MRI help diagnosis and height and weight changes, skeletal and sexual maturation. This
permits categorization of occipitalization (fusion) in 3 zones study’s evaluated various maturity measurements relative to
that may have prognostic implication. scoliosis progression. Physically immature girls with idiopathic
scoliosis were evaluated with serial spinal radiographs, skeletal
PAPER NO. 274
ages, Oxford pelvic scores, Risser sign determinations, heights,
◆Atlantoaxial Transarticular Screw Fixation in weights, sexual staging and serologies of IGF-1, IGFBP-3, DHEA-
Pediatric Patients S, estradiol, bone specific alkaline phosphatase and osteocalcin
levels. These were then correlated with the curve acceleration
Suken A Shah, MD, Wilmington, DE (n)
phase (CAP). The period and pattern of curve acceleration
Jason M Gallina, MD, New York, NY (n) always began during Risser 0. Skeletal maturation using the
William G Mackenzie, MD, Wilmington, DE (n) Tanner-Whitehouse III (TWIII) RUS method was superior to all
Jeffrey A Campbell, MD, Jeffersonville, IN (n) other dimensions of maturity determination. Regression of the
Abstract: The management of atlantoaxial instability in children scores provides good estimates of maturity relative to the period
is a multifaceted challenge due the variability of pathology and of curve progression (Pearson r=0.93). The initiation of this
anatomical considerations. Transarticular screw fixation is a period occurs simultaneously with digital changes from TWIII
biomechanically stable and highly effective method to achieve stage F to G. At this stage, curves also separate into rapid,
arthrodesis, but children pose unique and significant problems moderate, and low acceleration patterns with specific curve types
in successful screw placement. We discuss our experience at a for the rapid (Lenke 1 and 3) and moderate groups (Lenke 2, 4,
single institution with this technique in children and report the 5, and 6). The low acceleration group is not confined to a
indications, outcomes and complications. Eleven children specific curve type. The curve acceleration phase (CAP) separates
underwent arthrodesis using at least one transarticular screw. curves into various types of progression. The TWIII RUS scores
The mean age at surgery was 8 years (range 4-14) and the mean are highly correlated with timing relative to the CAP and provide
follow up was 16 months (range 6-36). The indication was better maturity determination and prognosis during adolescence
atlantoaxial instability with the diagnoses as follows: os odon-
toideum (3 patients), spondyloepiphyseal dysplasia (3 patients),

522 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 523

than the other parameters tested. Accurate skeletal maturity implant failure (W group: 5, H group: 2), and 12 cases of radi-
determination should be used as the primary maturity measure- olucency surrounding the lowest implant (W group: 9, A group:
ment in girls with idiopathic scoliosis. 2, PS group: 1). Although there were four neurological compli-
cations (three degraded spinal cord monitoring, one failed
PAPER NO. 276 wake-up test), there were no permanent neurological deficits.
Adolescents with Scoliosis Are Not Osteoporotic Apical pedicle screw constructs achieve and maintain better
correction without instrumentation failure compared to other
Elizabeth Ann Szalay, MD, Albuquerque, NM (n)
instrumentation constructs in scoliosis curves greater than 100
Patrick P Bosch, MD, Albuquerque, NM (n) degrees.
Richard M Schwend, MD, Kansas City, MO (n)
Frederick Sherman, MD, Albuquerque, NM (n) PAPER NO. 278
Brian Buggie, BS (n) Spinal Deformity in Neurofibromatosis: A Grading
Abstract: Studies have implied that adolescents with idiopathic
scoliosis have ‘osteoporosis.’ Per the International Society for
System to Predict Progression and Surgical Outcome
Clinical Densitometry (ISCD), these appellations are inappro- Daniel J Sucato, MD, Dallas, TX (a – Medtronic)
priate, and may be frightening and stigmatizing. Teens with scol- Anna McClung, RN, Dallas, TX (a – Medtronic)
iosis tend towards slender habitus and delayed bone age, both of Peggy Cook, RN (n)
which diminish Z-score. We propose that when body mass index Joel Lechevallier, Rouen, France (n)
(BMI), and delayed maturity are considered, Z-score normalizes. Abstract: Significant variation in spine deformity exists in
45 teens with idiopathic idiopathic scoliosis (AIS) had preoper- patients with neurofibromatosis. Although curves can be classi-
ative bone density (BMD) assessment by dual energy x-ray fied as dystrophic or non-dystrophic, this classification may not
absorptiometry (DXA). BMD was measured at lumbar spine and accurately predict curve progression or postoperative outcome
hips. Because the normative database does not rank Z-score following instrumentation and fusion. A retrospective review
according to BMI, 45 control subjects without scoliosis were was performed of patients who had scoliosis and neurofibro-
scanned, mirroring study subjects in age and BMI. Z-scores of matosis from a single institution. The medical record was
spine and hip in scoliotic subjects, while reduced, are within reviewed and radiographs were critically analyzed for the pres-
normal limits as defined by ISCD. If Z-scores are correlated to ence of dystrophic features (pencilling of the ribs, endosteal scal-
BMI, they fall on a curve that is the same as that for children loping, wedged vertebra, etc). The presence of each dystrophic
without scoliosis. Lower-than-normal Z-scores in children with feature was tabulated for each patient to determine the
AIS is due to slim habitus and possibly to delayed maturation dystrophic index (DI). There were 49 operative patients who
rather than presence or absence of scoliosis. When these factors were 11.8 years at surgery with average follow-up of 5.6 years.
are taken into account, children with AIS reflect Z-scores similar The approach was anterior alone in 12%, posterior alone in 44%
to non-scoliotic children of similar maturity and habitus. and combined in 44%. The main thoracic coronal Cobb preop-
eratively was 54.4º, corrected to 36.6º (32.7%) postoperatively
PAPER NO. 277

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

and was 37.5º (31.3%) at final followup. The dystrophic index
Comparison of Radiographic Outcomes for Scoliosis ranged from 11 to 63 (more severe). The DI increased between
Curves e100 degrees: Wires vs. Hooks vs. Screws the initial presentation and preoperatively in 57% of cases. DI
correlated with curve progression during the period from initial
Lawrence G Lenke, MD, Saint Louis, MO presentation to the preoperative time, and loss of postoperative
(a, c, e – Medtronic Sofamor Danek) coronal plane correction of both the thoracolumbar/lumbar and
Kei Watanabe, MD, PhD, Saint Louis, MO (n) thoracic curves.(P<0.05) The dystrophic index increased with
Keith H Bridwell, MD, Saint Louis, MO time in patients with neurofibromatosis and scoliosis and corre-
(a – Medtronic Sofamor Danek) lates with curve progression, and loss of correction following
Yongjung J Kim, MD, Fort Lee, NJ (n) surgery. This radiographic parameter may be utilized in the treat-
Kota Watanabe, MD, PhD, Saint Louis, MO (n) ment of these patients to better predict curve progression and
Marsha Hensley, RN, BS (n) those patients at risk for postoperative problems.
Georgia Stobbs, RN, BA, Saint Louis, MO (n) PAPER NO. 279
Abstract: Spinal fusion in scoliosis curves >100º are challenging
surgeries. Our purpose was to compare the radiographic Efficacy Of Preoperative Erythropoietin
outcomes by different techniques and anchors in the surgical Administration In Pediatric Neurogenic Scoliosis
treatment of scoliosis >100º. Sixty patients (21 idiopathic, four Patients
congenital, and 36 neuromuscular) with >100-degree curves
Michael G Vitale, MD, New York, NY (a – Ortho Biotech)
(range; 100-158º) who underwent spinal fusion via different
techniques and having anchors on the apical levels, were include Hiroko Matsumoto, MA, New York, NY (n)
for analysis. All patients had a minimum 2-year follow-up David Privitera, BA (n)
(mean, 4.2; range 2.0-10.5) and were classified into Group W Joshua E Hyman, MD, New York, NY (a – Ortho Biotech)
(wires, n=25), Group H (hooks, n=18), Group A (anterior verte- Linda Waters, NP, Brewster, NY (n)
bral screws, n=6), and Group PS (pedicle screws, n=11), based on David Price Roye Jr, MD, New York, NY (a – Ortho Biotech)
the type of apical anchor utilized. There were no statistically Abstract: A recent study at our institution demonstrated the effi-
significant differences between the groups for gender, age, cacy of rhEPO in pediatric idiopathic scoliosis patients, but
number of levels fused, or preoperative main curve Cobb angle. suggested the possibility of an ‘erythropoietin resistance’ in the
The PS group showed a significantly greater amount of correc- pediatric neurogenic scoliosis population. The purpose of this
tion than the other groups (p<0.0001) and smaller correction study is to investigate this finding further by analyzing the effect
loss than the W group (p<0.05) at final follow-up. There were of rhEPO on hematocrit (Hct) and transfusion rates in patients
four pseudarthroses (W group: 3, H group: 1), seven cases of

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
523
PPSE 07:Layout 1 1/12/07 1:41 PM Page 524

with neurogenic scoliosis. Sixty one patients with neurogenic PAPER NO. 281
scoliosis who underwent anterior and/or posterior spinal instru- Health Related Quality of Life in Children with
mentation at the age of 18 years and younger were identified
retrospectively. Thirty five children received preoperative rhEPO, Thoracic Insufficiency Syndrome
while 26 patients did not receive rhEPO. We found no signifi- Michael G Vitale, MD, New York, NY (a – Synthes Spine)
cant difference in comorbidities, numbers of level fused, Cobb David Price Roye Jr, MD, New York, NY (a – Synthes Spine)
angle or rates of pelvic fixation in two groups. Neurogenic scol- Hiroko Matsumoto, MA, New York, NY (n)
iosis patients who received RhEPO had a significantly higher Randal R Betz, MD, Ocean City, NJ (a – Synthes Spine)
preoperative Hct level (p=0.01) and postoperative Hct level John B Emans, MD, Boston, MA (a – Synthes Spine)
(p=0.02) than their non-RhEPO counterparts. Patients treated
David Lee Skaggs, MD, Los Angeles, CA (a – Synthes Spine)
with rhEPO had a 57.1% rate of transfusion while those without
rhEPO had a 50.0% rate although there was no significant differ- John Taylor Smith, MD, Salt Lake City, UT (a – Synthes Spine)
ence. The administration of rhEPO had no significant effect on Kit M Song, MD, Seattle, WA (a – Synthes Spine)
reducing the likelihood of transfusion in neurogenic patients in Robert Murray Campbell Jr, MD, San Antonio, TX
this study. While we acknowledge that selection and time bias, (a, c – Synthes Spine)
these data stand in stark contrast to previous work examining the Abstract: The purpose of this study is to compare quality of life
efficacy of rhEPO in averting transfusion in idiopathic popula- (QOL) of children with TIS, prior to implantation of VEPTR,
tions. We hypothesize that anemia of chronic disease, rhEPO with previously published QOL of healthy children. The Vertical
resistance, preexisting coagulopathies, and the nature of surgery Expandable Prothestic Titanium Rib (VEPTR) was specifically
in these children all play a role in obscuring the relationship designed to treat Thoracic Insufficiency Syndrome (TIS) by
between preoperative Hct and transfusion rates. allowing growth of the thoracic cavity and control/correction of
spine deformity. Patients were abstracted from the multicenter
PAPER NO. 280 VEPTR registry that was part of the original IDE of the device. The
Review of Surgical Treatment of Scoliosis in Child Health Questionnaire Parent Form (CHQ-PF) was
routinely collected on all patients older than 5 years of age. Forty
Children with Osteogenesis Imperfecta five childrenwith various conditions form the basis for our
James J McCarthy, MD, Philadelphia, PA (b – EBI) analysis. There were significant differences between study
John P Dormans, MD, Philadelphia, PA (b – Medtronic) patients and healthy children in many QOL domains (p<.05).
Ross Chafez, MPH, DPT (n) Children in Rib Fusion (RF, N=15), Hypoplastic Thorax
Jared Friedman, BA (n) Syndrome (HT, N=17) and Progressive Spinal Deformity (PS,
Timothy Roberts, BA (n) N=13) diagnostic categories scored significantly lower than
Brian Newton, BS (n) healthy children in Physical Functioning, Parental Impact-
Randal R Betz, MD, Ocean City, NJ (e – DuPuy, Medtronic, Emotional, Parental Impact-Time, and Physical Summary.
Children with RF also had significantly lower than normal scores
Synthes, Osteotech, Nuvasive, Spinevision)
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

in Family Activities and Psychosocial Summary domains. In the

Abstract: Scoliosis is common in children OI (osteogenesis Role/social Limitations Physical, General Health Perceptions
inperfecta), and difficult to treat. There is little literature focused and Family Activities domains, children with HT scored signifi-
on the results of treatment, making clinical decisions more diffi- cantly lower than the normal. Children with PS reported signif-
cult. The purpose of this study is to evaluate the incidence of icantly lower scores than the normal in the General Health
scoliosis in children with OI and determine the success of Perceptions domain. Patients with thoracic insufficiency
surgical treatment This is a retrospective IRB approved chart and syndrome have significant and profound perturbations in QOL
radiographic review of all patients with OI that have undergone when compared with other children. These scores are among the
treatment for scoliosis. 288 patients with OI, 83 (28.8%) were lowest observed in pediatric populations. Current efforts are
followed for scoliosis, of which 13 underwent spinal fusion. The underway to better understand the clinical features that have the
mean age at the time diagnosis for those with scoliosis was 8.9. most profound effects on the life of these children. These data
The mean age of those undergoing spinal fusion was 12.8 years. will serve as an important baseline on ongoing studies of these
For those undergoing spinal fusion there were 10 posterior spine patients after VEPTR implantation.
fusions (8 with instrumentation), 2 combined anterior and
posterior fusions , and one ASF alone. Preoperative (primary) PAPER NO. 282
curve magnitude was 56.9 degrees, which decreased to 34.4
postoperatively and was 41.6 at final follow up. There were 10 Loss of Spinal Cord Monitoring in Children during
complications in 8 patients (62 %), this included 3 wound Thoracic Kyphosis Correction with Spinal Osteotomy
problems, 2 with pain over the fusion, 2 with need for further Lawrence G Lenke, MD, Saint Louis, MO
instrumentation, one with psudeoarthrosis that necessitated (a, c, e – Medtronic Sofamor Danek)
revision, one with a plural injury and one that had a slow return Gene Cheh, MD, Seoul, Republic of Korea (n)
to ambulation. This study demonstrates that although scoliosis
Yongjung J Kim, MD, Fort Lee, NJ (n)
is common in children with OI, surgery is not commonly under-
taken. When surgery is performed, correction can be achieved Michael David Daubs, MD, Salt Lake City, UT (n)
but it carries a high risk of complications. Anne Padberg, MD, Saint Louis, MO (n)
Georgia Stobbs, RN, BA, Saint Louis, MO (n)
Marsha Hensley, RN, BS (n)
Abstract: To determine the incidence of, etiology for, and correc-
tion method of neurogenic motor-evoked potential (NMEP)
loss associated with pediatric spinal osteotomies for kyphosis
correction. 36 pediatric patients with useful lower extremity
function underwent a corrective spinal osteotomy for rigid

524 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 525

kyphosis at one institution. Diagnoses included Scheuermann’s PAPER NO. 284

kyphosis (n=13), congenital kyphosis (n=5), hemivertebra The Natural History of Scoliosis in Children with
(n=6), neuromuscular kyphosis (n=4), connective tissue disor-
ders (n=3), neurofibromatosis (n=2), and miscellaneous (n=3). Spastic Quadriplegic Cerebral Palsy
All osteotomies performed were at the spinal cord level, which Suken A Shah, MD, Wilmington, DE (n)
included vertebral column resection (n=6), posterior hemiver- Hakam Senaran, MD (n)
tebra excision (n=6), pedicle subtraction osteotomy (n=3), and Kirk W Dabney, MD, Wilmington, DE (n)
multiple Smith-Petersen osteotomies (n=21). Average preopera- Joseph Glutting, PhD, Wilmington, DE (n)
tive kyphosis was 79º (range 32-140º) and average correction Freeman Miller, MD, Wilmington, DE (n)
was 37º (range 0-59º). There were seven cases (19%) of intra-
Abstract: The natural history of scoliosis and risk factors for
operative NMEP loss. Signal loss occurred prior to corrective
progressive scoliosis in children with spastic quadriplegic cere-
maneuver (n=1), during corrective maneuvers (n=5), and 70
bral palsy (CP) await clarification. The effect of adolescent
minutes after completion of correction (n=1). Correction of
growth spurt on the progression of scoliosis in CP has not been
Scheuermann’s kyphosis through multiple Smith-Petersen
clearly defined. To define the natural history of scoliosis, risk
osteotomies (5/14, 36%) and performance of a thoracic verte-
factors for progressive scoliosis, and the effect of adolescent
bral column resection (2/6, 33%) demonstrated the highest risk
growth spurt on the progression of scoliosis in children with
for NMEP signal loss. With elevation of blood pressure (mean
spastic quadriplegic cerebral palsy. A retrospective review of the
arterial pressure >80mmHg) and release of correction, NMEP
medical records and radiographs of 135 cerebral palsy patients
signals reappeared in all cases in an average 18 minutes (range
followed at the same institution who had adequate radiographs
5-52), and surgery was successfully completed. Postoperatively,
of the spine at initial and follow up presentation and who had
all patients had a normal neurological exam. The incidence of
at least 25 degrees of scoliosis at follow up was performed. The
intraoperative NMEP signal loss during spinal osteotomies for
effects of curve type, adolescent growth spurt, functional capacity
spinal cord level kyphosis correction in pediatric patients was
of the patient and surgically treated previous hip subluxation
19%. Correction maneuvers combined with hypotension were
were evaluated on the rate of curve progression and pelvic obliq-
the common etiologies. Reduction in the degree of kyphosis
uity. The mean rate of curve progression was found to be 13.9
correction and blood pressure elevation reversed signal loss in all
degrees/year in spastic quadriplegic children. Scoliosis was diag-
cases.
nosed and treated at an earlier age in wheelchair bound patients
PAPER NO. 283 compared to ambulatory patients. The rate of curve progression
increased proportionately to the worsening functional capacity
Thoracolumbar Scoliosis: Comparison of Single Rod of the patient. Using analysis of covariance, juvenile patients(<10
Anterior Surgery with/without Anterior Support years at last follow up) had significantly higher rate of curve
Daniel J Sucato, MD, Dallas, TX (a – Medtronic) progression than the adolescent patients(>10 years old at initial
Sundeep Agrawal, BA (n) presentation). Surgically treated previous hip subluxation signif-
icantly increased the magnitude of pelvic obliquity. Curve type

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

Anna McClung, RN, Dallas, TX (a – Medtronic)
and gender have no effect on rate of curve progression. Lumbar
Charles Eugene Johnston II, MD, Dallas, TX (a – Medtronic) curves were the most common. The adolescent growth spurt has
Abstract: Many implant options are available for anterior treat- no effect on the rate of curve progression, but most curves
ment of thoracolumbar/lumbar (TL/L) scoliosis with a trend increased with growth. The spasitic quadriplegic patients who
toward stiffer implants. There are no large studies comparing had previous hip subluxation should be followed closely for
single 6.35 mm diameter rod constructs with and without ante- pelvic obliquity, to protect them from the potential complica-
rior structural support. A retrospective review was performed of tions of pelvic obliquity such as sitting inbalance, pressure ulcers
all patients who had an anterior spinal fusion and instrumenta- and hip pain. Gender and curve type has no significant effect on
tion (ASFI) for TL/L scoliosis using a 6.35 diameter rod rate of curve progression. Spastic quadriplegic cerebral palsy
comparing those who did and did not have structural anterior patients who developed curves at less than 10 years of age and
support. There were 86 total patients: 50 did not have anterior who are nonambulatory with previous or co-existing spastic hip
structural support (No SAS group) and 36 did (SAS group). All disease should be monitored at frequent intervals and their care-
had a single 6.35 mm rod. There were no differences between takers counseled on the natural history of progressive scoliosis
the No SAS and SAS groups in age (14.8 vs. 14.9 years) or gender since they have highest risk of curve progression.
(82.9 vs. 91.6% female). Radiographic analyses demonstrated no
difference between the No SAS and SAS groups in preoperative PAPER NO. 285
coronal curve magnitude (54.3 vs. 53.4°). Patients in the SAS
group had improved postoperative instrumented lordosis (-1.0°
Natural History of Congenital Lumbosacral
vs. -6.3°) and maintenance of instrumented lordosis (6.9° vs. - Scoliosis
1.9°), less loss of coronal correction (6.5 vs. 3.3 degrees) and Lindsay M Crawford, BS, Houston, TX (n)
greater postoperative coronal correction (60.2% vs. 69.3%) Richard Justis Haynes, MD, Houston, TX (n)
(p<0.05). The incidence of pseudoarthrosis (30.0 vs. 8.3%) and Robert Huang, MD, Houston, TX (n)
postoperative complications (50.0 vs. 22.0%) were less in the Elroy Sullivan, PhD, Houston, TX (n)
SAS group. (p<0.05). When performing ASFI with a 6.35 mm
Abstract: The purpose of this study was to determine risk and
diameter rod for thoracolumbar/lumbar scoliosis, the improve-
rate of progression of lumbosacral congenital scoliosis. Fourteen
ment and maintenance in sagittal plane lumbar lordosis is
patients with congenital scoliosis due to hemivertebra or bar at
significantly better when structural anterior support is utilized
the lumbosacral junction, treated non-operatively from August
and the incidence of complications and pseudoarthrosis is less.
2004 to March 2006, were retrospectively reviewed. Full length
spine PA radiographs were reviewed. Radiographic measure-
ments specifically included Cobb angle of the lumbosacral and
compensatory curves, spinal balance, truncal balance, and pelvic

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
525
PPSE 07:Layout 1 1/12/07 1:41 PM Page 526

obliquity. Four of the fourteen patients had progression of the PAPER NO. 332
lumbosacral curve giving a risk of progression of 28.6%. The Age Related Patterns of Injury in Children Involved
mean progression of the lumbosacral curve in these four patients
over 9.0 years mean follow-up was 9.5º± 3.7º. The average rate in ATV Accidents
of progression was 1.1º per year. Of the ten patients that had Ethan Kellum, MD, Augusta, GA (n)
measurable compensatory curves, four had progression (40%) Jeffrey R Sawyer, MD, Germantown, TN (n)
of the compensatory curve. The mean progression of the Aaron Creek, BS (n)
compensatory curve in these four patients over 8.7 years mean Ross Dawkins, BS (n)
follow-up was 14.5± 3.7º. There was no significant difference in
Abstract: ATV accidents are a significant source of morbidity in
number that progressed between patients who were braced
the pediatric population. We reviewed ATV-related admissions to
(33%) versus non-braced (43%).The mean change in spinal
a pediatric trauma center over a 2 year period to determine
balance over 5.8 years mean follow-up was 0.90 cm ± 1.66. The
patterns of injury. A retrospective chart review was performed for
mean change in truncal balance was 0.93 cm ± 1.27. The mean
a pediatric trauma center over a 2 year period. Fractures, soft
change in pelvic obliquity was 0.7º ± 2.8. The risk of progression
tissue injuries, body mass index and pediatric trauma scores
of the lumbosacral curve was 28.6% with a mean progression in
were obtained. Statistical analysis was performed using Excel. We
those that progressed of 9.5º± 3.7º with a rate of 1.1º per year.
identified 96 consecutive children who had been injured riding
Bracing does not appear to be effective in altering the natural
an ATV with a mean age of 11.03 years (range 2-16). Sixty seven
history of the primary congenital or compensatory curves.
percent were male, 33 percent were female. The mean pediatric
trauma score was 10.18. There were 78 total fractures, 7 were
PAPER NO. 331
open fractures. The median fractures per child was 1 and at least
Osteogenesis Imperfecta Misdiagnosed as Child 72 percent of children sustained one or more fractures. There
Abuse were 41 long bone fractures, 25 in the lower extremity and 16 in
Mininder S Kocher, MD, MPH, Boston, MA (n) the upper. There were 5 spine fractures, 10 skull fractures and 15
facial fractures.Associated injuries included closed head injuries
Laura Dichtel, AB, Boston, MA (n)
in 23 percent, abdominal injuries in 18 percent, and thoracic in
Ingrid Holm, MD, MPH (n) 5 percent of patients. 55 percent of children required surgical
Abstract: The differential diagnosis of child abuse includes treatment.Children younger than 12 had a statistically signifi-
osteogenesis imperfecta (OI). Mild phenotypes of OI may be cantly increased number of both long bone and lower extremity
misdiagnosed as child abuse. The purpose of this study was to fractures than older children. The total number of fractures per
review the experience of families in which OI was misdiagnosed patient was similar. ATV related accidents are a considerable
as child abuse. Sixty-one potential cases of misdiagnosis were source of morbidity in the pediatric population. Awareness of
identified from a lay support organization: ‘Protect Our associated injuries as well as age-related fracture patterns will
Families.’ Upon review of the medical records, 33 cases were lead to improved diagnosis and treatment of these patients.
identified with a genetically confirmed diagnosis of OI (skin
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

biopsy or DNA blood test). Excluded cases included those with PAPER NO. 333
an unclear diagnosis, temporary brittle bone disease (TBBD),
and idiopathic bone disorders. Questionnaires were given to
Racial and Economic Disparity and the Treatment
families to describe their condition and experiences. There were of Pediatric Fractures
14 male and 9 female children. Mean age at presentation was 7.1 James D Slover, MD, Boston, MA (n)
months. Presenting symptoms included pain (14), swelling (7), Tor Tosteson, ScD (n)
decreased limb movement (5), or unusual limb position (2). Jennifer Gibson, MS (n)
Original presentation was to the ER (18) or doctor’s office (15). Brian G Smith, MD, Hartford, CT (n)
Report to DSS was by an ER physician (18), pediatrician (5),
Kenneth J Koval, MD, Lebanon, NH (n)
family physician (3), orthopaedic surgeon (2), or other. In 9
cases, doctors did not discuss the diagnosis with the family Abstract: Disparity in the treatment of various medical condi-
before police hold. All patients had radiographs of the injury tions in patient groups with differing racial and economic back-
and additional imaging was performed in 32 patients. Multiple grounds has increasingly been reported. This paper examines the
fractures were found in 28 children with an average of 7 frac- relationship between baseline racial and economic factors and
tures. 42% of patients had some physical exam or radiographic the treatment of pediatric long-bone fractures. The 2000
findings for OI. 70% of children were removed from the family Healthcare Cost and Utilization Project(HCUP) Kid’s Inpatient
and 62% of older siblings were removed from the family. 52% Database (KID)was used to retrospectively examine the inci-
of families were denied all medical records. The diagnosis of OI dence and treatment of pediatric fractures. Data were included
was made at a mean age of 10.5 months old. 94% of children for supracondylar humerus (n=2,957), femoral shaft (n=1,726)
had type I OI. Clinical or radiographic symptoms of OI were or radius and ulna forearm fracture (n=828) as their primary
present in 88% of children and there was a family history diagnosis were studied. Hispanic (78%) and black
suggesting OI in 52% of children. Mean $42,000 was spent by (82%)patients were more likely to receive closed reduction with
families on legal fees. The consequences of misdiagnosis of OI internal fixation (percutaneous pinning) of supracondylar
as child abuse are devastating to the family. OI should be consid- humerus fractures than whites(73%, p=0.02). Despite a fairly
ered in all cases of suspected child abuse. In children with any large sample size, differences in treatment of supracondylar
clinical, radiographic, or family history features of OI, genetic humerus fractures across primary payer or income groups were
testing should be performed. not statistically significant. Patients with femur fractures and
private insurance were more likely to be treated with an external
fixation device(7.2%) than patients in the Medicaid (3.8%) or
self-pay (4.5%) groups(p=0.015). No statistically significant
difference was found in the treatment of forearm fractures across
racial, primary payer or income groups. Racial and economic

526 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 527

disparity is an important issue in medicine today. This study did fracture healing with less than 10 degrees of angulation after a
demonstrate statistically significant differences in the treatment single procedure, loss of rotation less than 20 degrees compared
of pediatric supracondylar humerus across racial groups, with to the opposite forearm, and normal neurovascular status. 34
Blacks and Hispanics being more likely to receive percutaneous patients, average age 10.6 years, were treated during the study
pinning of these injuries than Whites. Private insurance patients period, with 18 stabilized by SBF and 16 by BBF. Sixteen of 16
were also more likely to have femoral shaft fractures treated with fractures treated with BBF had an acceptable outcome. All frac-
an external fixator device than patients with Medicaid or self-pay tures treated with BBF had angulation and translation of both
as their primary payer. However, the clinical significance of these bones; the radius/ulna fracture site distance varied from 0-3.5
differences is not clear. Further research is needed to gain a more cm. Fourteen of 18 fractures treated with SBF had an acceptable
complete understanding of disparities in medicine, and their outcome. Of the fractures successfully treated with SBF, 7 of 14
etiologies, in order to work towards optimizing the quality of cases had one of the fractured bones angulated without fragment
medical care for all patient groups. translation; all cases had a distance of less than 2.2 cm between
the radius/ulna fracture sites. 2 of 4 failures of SBF had early loss
PAPER NO. 334 of alignment secondary to loss of fixation and were revised. Two
Pediatric Orthopedic Patients Presenting to a patients healed with 12 degrees and 15 degrees of angulation
without significant loss of rotation. SBF failures were attributed
University Emergency Room after Visiting another ER to technical errors (wire cut-out and poor casting) in 2 patients.
Sanjeev Sabharwal, MD, Newark, NJ (n) Two other patients had progressive angulation of the bone not
Abstract: The purpose of our study was to analyze demographic stabilized; fracture site distance was greater than 2.5 cm in these
information, including health insurance status, of children with patients. Patient age, mechanism, and initial fracture angulation
extremity injuries seen at a University Hospital emergency room were not significantly different between the SBF and BBF groups.
(UH ER) after visiting another ER for the same complaint. A SBF is successful in stabilizing pediatric forearm fractures when
database of pediatric orthopedic consults requested for extremity one of the two fractured bones is angulated without translation,
injuries at UH ER was reviewed. Over a 30 month period, 125 or when the distance between the radius/ulna fracture sites is less
children, of whom 82% had public insurance were identified. A than 2.2 cm. Successful use of SBF requires careful patient and
closed fracture was diagnosed in 117 patients, 94% of whom fracture pattern selection. BBF may be a more reliable method of
were discharged from UH ER following cast application. There treating pediatric forearm fractures despite theoretical increased
was no difference with regards to patients’ age, gender, ethnicity, risks.
diagnosis and time to presentation at the initial ER between
private and public insurance groups. 52% of children with PAPER NO. 336
private insurance received orthopedic care within 24 hours Accuracy of Emergency Room Physician
compared to 22% with public insurance (p<0.05). Children
with public insurance were more likely to have visited another Interpretation of Pediatric Elbow Fractures
health facility besides the initial ER before presenting to UH ER. Michael Wade Shrader, MD, Peoria, AZ (n)
David Joseph Jacofsky, MD, Sun City West, AZ (n)

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

74% of privately insured patients presenting to UH ER arrived
via ambulance, compared to 34% with public insurance (p < Mark D Campbell, MD, Sun City West, AZ (n)
0.001). Majority of children with an extremity injury requiring Abstract: Elbow fractures are the most common operative upper
orthopedic consultation at a tertiary level ER after visiting extremity fracture in children. Although many reports on pedi-
another ER had an uncomplicated fracture requiring cast treat- atric elbow fractures are from tertiary care centers with residents
ment only. There was a delay in receiving definitive orthopedic available to evaluate the patient, most children present at insti-
care for patients with public health insurance. To optimize tutions where the emergency room (ER) physician is the primary
utilization of resources and avoid delay in treatment, children point of care. Orthopedic surgeons rely on the ER physician to
diagnosed with an uncomplicated extremity fracture may be accurately communicate and convey the nature of the injury. The
better served by receiving a more comprehensive evaluation and purpose of this prospective study is to determine the accuracy of
follow up, irrespective of the health insurance status. radiograph interpretation of pediatric elbow fractures by ER
physicians. All consecutive pediatric patients with operative
PAPER NO. 335 elbow fractures that presented to a tertiary care orthopedic
Intramedullary Fixation of Pediatric Forearm referral center over a six month period were included. Thirty frac-
Fractures: Single vs. Both-Bone Surgery tures were identified. The ER physicians’ radiograph interpreta-
tion was compared to the final interpretation by the treating,
Anjan Rajni Shah, MD, Philadelphia, PA (n) staff pediatric orthopedic surgeon. Accuracy rates were deter-
Rakesh Pravinkumar Mashru, MD, Exton, PA (n) mined for overall agreement, and by fracture subtype. The ER
Martin Joseph Herman, MD, Philadelphia, PA (n) physicians were from a variety of settings, including rural,
Abstract: In an effort to minimize surgical time and exposure community, and pediatric hospitals. Overall accuracy of the ER
and reduce potential risks, our practice has begun to attempt to physicians’ interpretation was 53% (16/30). The fracture type
use intramedullary (IM) single bone fixation (SBF) over both- that was most often accurately described was type 3 supra-
bone fixation (BBF) to stabilize pediatric diaphyseal forearm condylar humerus fractures (68% accuracy). The fracture type
fractures that fail conservative treatment. This study examines that was most often misdiagnosed was lateral condyle fractures
clinical and radiographic parameters that may predict success of (0% accuracy in this series). ER physicians had difficulty in accu-
SBF and compares outcomes of SBF vs. BBF. We reviewed the rately describing pediatric elbow fractures. This study under-
records and radiographs of patients wth diaphyseal forearm frac- scores the importance of educating ER doctors and residents in
tures treated with IM fixation consecutively between 1997-2004 pediatric fracture interpretation to optimize patient outcomes.
at our institution. Demographics, injury description, fracture Orthopedists need to be vigilant when taking care of these
pattern, surgical treatments, and clinical and radiographic patients to prevent unnecessary complications.
outcomes were reviewed. An acceptable outcome was defined as

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
527
PPSE 07:Layout 1 1/12/07 1:41 PM Page 528

PAPER NO. 337 different than reported normal values (p=0.007). Despite this,
Neurovascular Injuries Associated with Pediatric there was no difference in forearm rotation between groups.
Complication rates were also similar between groups. There
Upper Extremity Fractures were no significant differences between groups for healing or
Peter M Waters, MD, Boston, MA (n) magnitude of radial bow. There was a difference in location of
Donald S Bae, MD, Boston, MA (n) maximal radial bow, with no effect on forearm rotation. Based
Robert J Yu, BS, MA (n) on similar functional and radiographic outcomes with nailing
Abstract: While the majority of neurovascular (NV) injuries asso- and plating, the operative technique in children 10 to 16 years
ciated with upper extremity fractures resolve with fracture care, old can be chosen based upon fracture characteristics and
persistent problems can lead to functional limitations. We surgeon preference.
reviewed our institution’s experience with these injuries and
propose a treatment algorithm for injuries in skeletally imma-
PAPER NO. 339
ture patients. A retrospective analysis of patients from 1996- Lateral Acetabular Growth Stimulation Following a
2006 was performed. Age of injury, fracture type and care, and Labral Support Procedure in Perthes Disease
nature of NV compromise and care were recorded. Patients with
J Richard Bowen, MD, Wilmington, DE (n)
unresolved neuropathy were also reviewed. There were 297
patients identified (185 males and 113 females). Average age at Marcin E Domzalski, MD, Lodz, Poland (n)
time of injury was 9.6 years (range 1 month to 17.9 years). Joseph Glutting, PhD, Wilmington, DE (n)
Average clinical and radiographic follow-up was 11 months. The Aaron G Littelton, BSc (n)
most common fractures were supracondylar humerus fractures Abstract: The main goal of containment treatment in Legg-Calvé-
(n=145,47 %), forearm fractures (n=60,20%), and multiple Perthes disease is to prevent hip deformity, which leads to
combined fractures (n=37,12%). The most commonly injured arthritis in adulthood. Recently, the shelf arthroplasty (the labral
nerve was the median nerve (n=128,41%). The most commonly support procedure) has been proposed as a method for contain-
injured vessel was the brachial artery (n=17,89%). Overall, 76% ment. The purpose of this study was to evaluate growth stimula-
of nerve injuries resolved spontaneously without additional tion of the acetabulum in unilateral Legg-Calvé-Perthes disease
treatment. Nerve decompressions (69), neuroma resections and by measuring its depth and height following treatment with the
direct repair (7), nerve grafts (2), and vascular repair requiring labral support procedure. Non-involved, contralateral hips and
vein grafts (4) were performed. Follow-up care revealed that all cases treated with proximal femoral varus osteotomy were used
these cases resulted in sufficient healing with no need for addi- to compare growth. Sixty-five consecutive cases of unilateral
tional treatment. For closed fractures associated with a nerve Legg-Calvé-Perthes disease treated with the labral support proce-
palsy at the initial time of injury, observation after reduction is dure (49) or a proximal femoral varus osteotomy (16) were
recommended. Nerve exploration acutely is reserved for open available with 5 years follow-up after surgery and with radi-
fractures and fractures requiring open reduction. Vascular ographic and clinical data from the time of surgery as well as at
injuries are uncommonly associated with upper limb fractures 1, 3, and 5 years. Acetabular dimensions (depth, height, and
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

and most resolve with timely/appropriate fracture care. total depth with shelf) were measured and to eliminate radi-
Avascular limbs after fracture reduction require emergent ographic magnification error, the data was expressed in ratios
surgical revascularization. between the involved and uninvolved sides. Preoperatively, both
surgical groups were comparable. Acetabular depth indexes at
PAPER NO. 338 the time of surgery were not different between groups (p=0.46).
Comparison of Intramedullary Nailing to Plating for Postoperatively, at 1, 3 and 5 years of follow-up, the mean depth
indexes in the labral support group were significantly higher
Forearm Fractures in Older Children than in the proximal femoral varus osteotomy group (F=5.417,
Keith R Reinhardt, BS, New York, NY (n) p=0.001), and trend analysis showed a significant quadratic
David M Scher, MD, New York, NY (n) effect over time (F=13.132, p = 0.001) in the labral support
Daniel William Green, MD, New York, NY (n) procedure group. Acetabular height indexes at the time of
Sheryl Handler-Matasar, MD, Chagrin Falls, OH (n) surgery were not different between groups, and showed 11% to
Debra Anne Sala, PT, New York, NY (n) 13% acetabular overgrowth. The acetabular height indexes in
Roger F Widmann, MD, New York, NY (n) both groups remained unchanged at follow-up (F=2.82, p=0.1).
The total depth index showed decreasing linear trend values over
Abstract: When operative stabilization of forearm fractures in
the period studied (F=35.115, p=0.001). Overgrowth of the
older children is necessary, the optimal method of fixation is
acetabulum occurs naturally, early in Legg-Calvé-Perthes disease
controversial. 31 patients who underwent operative fixation of
and is more pronounced in its height. The labral support proce-
midshaft radius and ulna fractures were divided into nailing and
dure induces additional lateral growth of the true acetabulum
plating groups, and compared retrospectively according to peri-
(excluding the shelf) for 3 years following surgery, while a prox-
operative data and outcome measures (union at 3 and 6
imal femoral varus osteotomy does not. Thus, beneficial effects
months, loss of forearm rotation, restoration of radial bow
of the labral support procedure are lateral acetabular growth
magnitude and location, and complications). The nailing group
stimulation, prevention of subluxation, and shelf resolution
had 19 patients, mean age 12.5 years (range 10-14.6), and the
after femoral epiphyseal reossification.
plating group had 12, mean age 14.5 years (range 11.9-16).
Groups were similar for gender, arm injured, fracture location,
AO/OTA classification, and number of open fractures. Duration
of surgery and tourniquet use were significantly shorter in the
nailing group. No differences were found between the groups for
union at 3 or 6 months. At latest follow-up, radial bow magni-
tude was similar for the two groups and restored to normal in
both. Radial bow location in the nailing group was significantly

528 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 529

PAPER NO. 340 more striking, favoring the surgical group, among those with
The Incidence of Chondrolysis and AVN in Later lateral pillar C classification: 22% versus 0% (operative vs
nonoperative) Good; 55% versus 0% Fair; 22% versus 100%
Second Side Slip of Patients with SCFE Poor. All of the non-surgically treated hips in the lateral pillar
Richard S Davidson, MD, Philadelphia, PA (n) category C had a poor outcome. Patients diagnosed with Perthes
Yakup Yildirim, MD, Philadelphia, PA (n) disease over the age of 6+2 years have a guarded outcome. Those
Severino R Bautista, Jr MD, Philadelphia, PA (n) classified with lateral pillar C disease did worse than those
Abstract: The purpose of the study was to identify the incidence, patients classified as lateral pillar B. Patients in both categories
complications (AVN \ chondrolysis) and slip severity of second did better if treated surgically than those treated non-surgically.
side slips in children who initially presented with unilateral Patients with the onset of symptoms over the age of 6+2 with
SCFE. The charts of 416 patients with SCFE operated between lateral pillar C disease treated non-operatively all did poorly.
1991-2004 were retrospectively evaluated. The patients were
grouped as having simultaneous bilateral, unilateral and later
PAPER NO. 342
second side slips. After excluding the patients with less than 2 Urgent Reduction, Fixation, and Arthrotomy for
year follow up, the remaining unilateral SCFE patients were eval- Unstable Slipped Capital Femoral Epiphysis
uated for the development of contralateral second side slip. The
Ryan Chen, MD, Saint Louis, MO (n)
incidence of AVN/chondrolysis and slip severity was assessed for
both the unilateral and second side slips. There were 189 J Eric Gordon, MD, Saint Louis, MO (n)
patients with simultaneous bilateral slips, 145 patients with Scott J Luhmann, MD, Saint Louis, MO (e – Medtronic)
unilateral slip and 82 patients with later second side slip. In the Matthew Barrett Dobbs, MD, Saint Louis, MO (n)
unilateral slip, 56 % had Gr I, 36 % had Gr II and 8 % had Gr Perry L Schoenecker, MD, Saint Louis, MO (n)
III slips. In the later second side slip, 78 % had Gr I, 12 % had Abstract: Complications associated with the surgical manage-
Gr II and 10 % had Gr III slips. Eleven patients with unilateral ment of unstable slipped capital femoral epiphysis (SCFE)
SCFE and 1 patient with sequential SCFE developed AVN. include chondrolysis, slip progression and avascular necrosis
Chondrolysis was present in 2 patients with unilateral SCFE and (AVN). These complications can have a devastating effect on the
4 patients with later second side SCFE. 36% of the unilateral long-term prognosis of unstable SCFE. The purpose of this study
slips developed a later second side slip during the follow up. was to report on the clinical outcome of a protocol used to
Twenty two percent of the second side slips had Gr II and III slips manage these injuries. Twenty-eight consecutive patients with
that are predisposed to develop osteoarthritis of the hip. Another thirty unstable SCFE over a ten year period underwent urgent
6 % developed AVN or chondrolysis. The overall risk of poor reduction with arthrotomy and fixation with two 6.5 millimeter
outcome for the second side slip is 28 % suggesting that prophy- cannulated screws. Positional reduction was performed in
lactic pinning is advisable. twenty-six cases and open reduction was performed in four
cases. Arthrotomy was percutaneous in sixteen cases and open in
PAPER NO. 341 four cases. Slip severity was mild in thirteen cases, moderate in

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

Perthes Disease: Combined Salter and Varus nine, and severe in eight according to Southwick. Time to surgery
from the onset of acute symptoms was less than 24 hours in
Osteotomies Compared to Nonoperative Treatment twenty-two cases, less than 48 hours in two cases and less than
Christine B Caltoum, MD, San Diego, CA (n) 72 hours in six cases. At mean follow-up of 5.5 years (range, 2.0-
William J Shaughnessy, MD, Rochester, MN (n) 11.2 y), four patients developed AVN (14.3 percent). One patient
Anthony A Stans, MD, Rochester, MN (n) with AVN developed slip progression (3.6 percent). No patients
Abstract: The natural history of Perthes Disease remains unclear, developed chondrolysis. Two patients reported mild hip pain
although it is known that older patients with significant femoral and two patients reported moderate hip pain at final follow-up.
head involvement do worse than younger patients having less We recommend urgent reduction with accompanying arthro-
extensive disease. The treatment remains controversial, with tomy and fixation via two cannulated screws for unstable SCFE.
bracing of little benefit. The purpose of this study is to compare With this protocol we have noted a low incidence of chondrol-
the results of 20 hips treated with simultaneous Salter and prox- ysis, slip progression and AVN.
imal femoral osteotomies to a similar group of 22 consecutive
hips treated nonoperatively. Patients were matched by age at PAPER NO. 343
onset of symptoms and lateral pillar classification. Outcomes Predictive Value of Lesion Size on Healing Potential
were measured using the Stulberg classification. The operative
group of 20 hips had age of onset from 6+5 to 10+0 years. Lateral
of Stable Juvenile OCD Lesions of the Knee
pillar classification was A in 0 hips, B in 11 and C in 9 hips. There Eric Wall, MD, Cincinnati, OH (n)
were 14 males and 6 females. Mean follow-up was 45.3 months. Jason Vourazeris, BS (n)
The nonoperative group of 22 hips had age of onset ranging Gregory Donald Myer, MS, Cincinnati, OH (n)
from 6+2 to 10+4 years. Lateral pillar classification was A in 1 Kathleen Emery, MD (n)
hip, B in 13 hips, and C in 8 hips. All patients were male. Mean Jon Divine, MD (n)
follow-up was 5+4 years. Hips treated with combined Salter and Timothy E Hewett, PhD, Cincinnati, OH (n)
varus osteotomies had better results than the non-surgical group Abstract: It is difficult to accurately predict the nonoperative
at final followup. In the surgical group, 30% achieved good healing potential for stable juvenile osteochondritis dissecans
results (Stulberg class I, II), 50% fair results (Stulberg III), and (JOCD) lesions at the time of initial diagnosis. The purpose of
20% poor results (Stulberg IV, V). In the non-surgical group, this study was to determine the prognostic value of MRI in stable
14% had good results, 27% fair, and 59% poor results. Among JOCD lesions of the femoral condyle. We studied 43 patients (48
the hips with lateral pillar B classification, results were better in knees) who all had stable JOCD lesion on an MRI scan (articular
the surgical group: 36% vs 15.5% (operative vs. nonoperative) cartilage intact) that was obtained at the time of diagnosis. All
Good; 45% vs 46% Fair; 18% vs 38.5% Fair. The results were patients were treated with 6-12 weeks of immobilazation

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
529
PPSE 07:Layout 1 1/12/07 1:41 PM Page 530

followed by knee bracing and activity restriction. The primary PAPER NO. 345
outcome measure was radiographic healing after 6 months or Treatment for Developmental Dysplasia of the Hip
nonoperative treatment. This was correlated with patient age,
gender, surface area normalized to knee size and location. With with the Pavlik Harness: Long-Term Results
nonoperative treatment, 16/48 lesions (33%) failed to progress Junichi Nakamura, MD, Chiba, Japan (n)
toward healing after 6 months while 32/48 (67%) cases Makoto Kamegaya, MD, Chiba City, Japan (n)
progressed toward healing. The mean surface area of the healed Yoshitada Harada, MD, Chiba City, Japan (n)
lesions was 204mm squared +/- 136 mm squared. Lesions that Takashi Saisu, MD, Chiba, Japan (n)
failed had a mean surface area of 288 mm squared +/-103 mm Takeshi Miyasaka, MD, Chiba, Japan (n)
squared (p-value = 0.03). NOrmalized surface area was signifi-
Shinji Yamamoto, MD, Chiba City, Japan (n)
cantly greater in the failed group (p = 0.0017). Age, gender or
location were not significant predictors of healing. Young Takayuki Nakajima, MD, Chiba City, Japan (n)
patients with stable JOCD may not heal under an nonoperative Hideshige Moriya, MD, Chuo-ku,Chiba, Japan (n)
protocol. Large lesions were less likely to heal after 6 months of Abstract: To clarify long-term results of developmental dysplasia
nonoperative treatment and may warrant earlier surgery. of the hip (complete dislocation) treated with a Pavlik harness
and supplementary operation. We reviewed the medical records
PAPER NO. 344 of 221 patients treated with the harness for developmental
Transphyseal Anterior Cruciate Ligament dysplasia of the hip. For inclusion the patients needed a complete
dislocation except for teratological dislocation and the harness
Reconstruction in Skeletally Immature Pubescent had to be the initial treatment which successfully reduced the
Adolescents dislocation. Patients were followed up at least until 14 years of
Mininder S Kocher, MD, MPH, Boston, MA (n) age. Thirty patients were excluded because of subluxation or tera-
Jeremy Scott Smith, MD, Orange, CA (n) tological dislocation. The harness treatment failed in 38 and
succeeded in 153 patients being a successful reduction rate of
Ben Lee, BA (n)
80%. One hundred and fifteen patients with 130 hips had been
Lyle J Micheli, MD, Boston, MA (n) followed up long enough with the mean follow-up period of 16
Abstract: The purpose of this study was to evaluate the outcome years and the follow-up rate of 75%. The mean age at the time of
of transphyseal ACL reconstruction with autogenous hamstrings harness application was 4.8 months and the mean time spent in
graft in pubescent adolescent skeletally immature patients. Sixty- the harness was 6.1 months. Supplementary operation was indi-
one knees in 59 skeletally immature pubescent adolescent cated in 22 hips (17%) for residual acetabular dysplasia defined
patients underwent ACL reconstruction with transphyseal (both by acetabular index (AI) >30º around 5 years of age. Overall satis-
femur and tibia) autogenous hamstrings graft with metaphyseal factory outcome (Severin I/II) was shown in 119 of 130 hips
fixation. Mean chronological age was 14.7 years old (range: 11.6- (92%), consisting of 100 of 108 hips (93%) treated with the
16.9), mean skeletal age was 14.4 years old (range: 12.0-17.0), harness only and 19 of 22 hips (86%) treated with additional
and maturity was Tanner stage 3 in all patients. There were 23
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

surgeries. Avascular necrosis of the femoral head was noted in 16

boys (39%) and 36 girls (61%). Mean follow-up was 3.6 years hips (12%). The long-term results were excellent owing to proper
(range: 2.0-10.2). The mean time interval from injury to recon- initial treatment and supplementary operations. AI was a reliable
struction was 3.8 months. Associated surgery at the time of predictor of residual acetabular dysplasia.
reconstruction included meniscal repair (17 knees) and partial
menisectomy (14 knees). Functional outcome was assessed PAPER NO. 376
using the IKDC subjective score and the Lysholm knee scale.
Objective examination included Lachman and pivot-shift exam-
Advanced Skeletal Maturity in Ambulatory Cerebral
inations graded per IKDC criteria. Radiographic examination Palsy Patients
was performed to evaluate for growth disturbance. Overall Norman Yoshinobu Otsuka, MD, Los Angeles, CA (n)
growth was assessed by measurement of height and clinical Kiran Gollapudi, BS (n)
assessment of leg-length inequality. Two patients underwent Brian Feeley, MD, Los Angeles, CA (n)
revision ACL reconstruction for graft failure at 14 months and 21
Abstract: The purpose of our study was to assess skeletal matu-
months after surgery (revision rate: 3.3%). The mean IKDC
ration in an ambulatory CP population and to determine the
subjective score was 89.5 (SD: 10.2) and the mean Lysholm knee
affects of body mass index, type of CP, and Gross Motor
scale was 91.2 (SD: 10.7). All patients had return to cutting and
Function Classification System (GMFCS) on skeletal maturity. A
pivoting sports. Lachman examination was normal in 51 knees
retrospective review was performed on 51 patients. Age, gender,
and nearly normal in 8 knees. Pivot-shift examination was
height, weight, BMI, type of CP, and GMFCS were recorded from
normal in 56 knees and nearly normal in 3 knees. The mean
the chart. Bone age was determined using the Oxford method.
growth in total height from time of surgery to follow-up was 8.2
Statistical analysis included bivariate and multivariate regression
cm (range: 1.2-25.4). There were no cases of clinically detectable
analyses. Significance was determined as a p value of <0.05.
leg-length inequality, clinical angular deformity, radiographic
There were 26 males and 25 females. All CP patients were inde-
growth disturbance, or radiographic angular deformity.
pendent ambulators. The average chronologic age of males was
Complications included three cases of arthrofibrosis requiring
7.1 years and 8.6 years for females. The average bone age was 9.9
manipulation under anesthesia and one stitch abscess.
years for males (p=0.03) and 10.6 years for females (p=0.079).
Transphyseal ACL reconstruction with autogenous hamstrings
48 of 51 (94%) patients had advanced bone age compared to
graft in pubescent adolescent patients provides for excellent
chronologic age. Bone age was significantly advanced compared
functional outcome with a low revision rate and a minimal risk
to chronological age for males (p=0.033) and showed a trend
of growth disturbance.
towards significance in females (p=0.079). In multivariate
analysis, quadriplegic CP showed a trend toward significance
(p=0.066) and GMFCS III was significantly associated with

530 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page iv.
PPSE 07:Layout 1 1/12/07 1:41 PM Page 531

advanced bone age in males (p=0.011). In females, quadriplegic PAPER NO. 378
CP and BMI<15 were significantly associated with advanced Functional Outcomes of Early Arthroscopic Bankart
bone age (p<0.05 in both). A majority of the ambulatory CP
patients had advanced bone age compared to chronologic age. Repair in Adolescents Age 11-18 years old
Patients with factors associated with advanced CP had advanced Lawrence Wells, MD, Philadelphia, PA (n)
bone age. Understanding factors that lead advanced skeletal Kristofer Jones, Philadelphia, PA (n)
maturation is important in planning the appropriate timing for Brent B Wiesel, MD, Bala Cynwyd, PA (n)
surgical intervention Theodore J Ganley, MD, Bryn Mawr, PA (n)
Abstract: Recurrent shoulder instability can significantly affect a
PAPER NO. 377
patient’s quality of life and place them at risk for extensive injury
Guided Growth for Angular Correction with repeated dislocations. Few studies have investigated the
Peter M Stevens, MD, Salt Lake City, UT precise role of arthroscopic Bankart repair (ABR) in a pediatric
(a, b, c – Orthofix, Inc.) population. The purpose of this paper was to evaluate the effi-
Abstract: The gold standard for treating pathologic angular cacy of ABR for recurrent anterior instability in adolescents. We
deformities in children has been corrective osteotomy. However, reviewed 32 consecutive ABRs in 30 pediatric patients. Both the
this requires hospitalization, pain management, immobilization clinical charts and operative narratives of each patient were
and often physical therapy upon cast removal. Neurovascular reviewed to determine the date and direction of first dislocation,
structures are at risk, blood loss may be an issue and muscle total number of dislocations prior to therapy, and initial form of
atrophy is common. Multiple or bilateral osteotomies may need treatment. Functional outcomes were measured using the single
to be staged. Under or over correction or loss of alignment may assessment numerical evaluation (SANE) score. 16 shoulders
further compromise the outcome. This report describes the failed initial nonoperative therapy prior to ABR, while surgical
results of guided growth using the 8-plate, allowing the physes stabilization was the primary treatment in 16 shoulders after
to gradually and safely correct the deformities, obviating the initial evaluation at our institution. The average patient age was
need for osteotomy in most cases. With IRB approval a prospec- 15.4 years (age 11-18 years) with an average follow-up of 16.4
tive study was undertaken; between 4/04 and 4/05 a consecutive months. In the initial nonoperative group, the average SANE
group of 34 patients with 65 segmental deformities underwent score was 91.3. There were 3 shoulder redislocations in 2 patients
implantation of extraperiosteal 8-plates (one per physis). The (18.75%). In the 16 shoulders treated with ABR as initial
surgery was performed on an outpatient basis; no immobiliza- therapy, the average SANE score was 90.8 and there were 2
tion was required and early weight-bearing was encouraged. shoulder redislocations in 2 patients (12.5%). ABR, as a primary
Patients ranged in age from 19 months to 17 years and in size procedure or following a trial of physical therapy, is an effective
from 13 kg to 140 kg at the time of implantation. The diagnoses treatment for traumatically induced instability in adolescents.
included: idiopathic (19), skeletal dysplasia (2), Blount’s (4), Primary ABR limits multiple recurring shoulder dislocations that
limb deficiency (3), /p trauma (2), Rickets (1) and genetic (1). likely hinder a patient’s quality of life and potentially places
Rather than compressing the physis, the plate serves as a tension them at risk for future sequelae.

PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

band providing hinge distraction at the periphery of the physis.
Complete correction of deformity was observed in 32 of 34 PAPER NO. 379
patients (63 of 65 deformities). Correction occurred over an Outcomes of Shoulder Reconstruction in Children
average of 11 months. The implants were removed when the with Brachial Plexus Birth Palsy
mechanical axis was neutral. Four patients, each being 11 years
Russell D Dedini, BA, San Francisco, CA (n)
or younger with idiopathic genu valgum, experienced recurrent
deformity due to rebound growth and were treated by repeat Michelle A James, MD, Sacramento, CA (n)
guided growth. There were no permanent physeal closures. Anita Bagley, PhD, Sacramento, CA (n)
Guided growth with an 8-plate provides a safe and cost effective George T Rab, MD, Sacramento, CA (n)
means of dealing with a variety of deformities in children of all Abstract: Children with brachial plexus birth palsy may undergo
ages. Multifocal and bilateral deformities may be corrected shoulder external rotation tendon transfers (ERTT) to improve
simultaneously. The deformities are typically addressed at or function. According to the WHO outcomes model, ERTT reduces
near the CORA (center of rotational axis of deformity), thereby impairment by improving range of motion (ROM), but has not
avoiding the creation of compensatory deformities. Correction been shown to improve activity and participation, and correla-
may be achieved in the frontal, sagittal or oblique plane. The tion between these outcome measures has not been established.
safety and efficacy of guided growth compare favorably to The PODCI is a well-validated questionnaire that addresses
osteotomy. If malrotation or limb length discrepancy persist, activity and participation components of function, and provides
these may be dealt with subsequently on an elective basis. We a valid assessment of pre-operative function in children who are
should rethink the routine application of osteotomies for the candidates for ERTT. The aim of this study is to determine
correction of pediatric angular deformities. By comparison, whether PODCI scores improve following ERTT, and whether
guided growth, is safe, simple, and suitable for any diagnosis at this improvement correlates with improvement in ROM. 23 chil-
almost any age, provided the physis is open. dren (average age 6.3 years) underwent pre- and 1 year post-
ERTT evaluations including shoulder ROM measurement, and
completion of the PODCI. Pre- and post-operative abduction
and external rotation and PODCI scores were compared, and
change in ROM was compared with change in PODCI scores.
Average shoulder abduction improved 35o (p<0.001) and
average external rotation improved 41o (p<0.001). PODCI
scores for Upper Extremity Function, Sports/Physical Function,
and Global Function improved significantly. Post-operative
abduction correlated with PODCI scores, but post-operative ER

The codes after the name are identified as: a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options, e-consultant or employee, and n-no conflicts disclosed. For full
information, refer to page iv.
531
PPSE 07:Layout 1 1/12/07 1:41 PM Page 532

and changes in ROM did not. For children with BPBP, ERTT is using Paley’s multiplier method. Analysis was performed with
associated with reduced impairment and improved activity and ANOVA testing to identify variables having prognostic influence
participation, and those with more abduction have better on predicted LLD. 59 patients (38 females, 21 males) had a
PODCI scores. However, ER measurements and PODCI scores mean age at latest follow-up of 10.5 yrs (1.08 to 28.3 yrs). The
do not correlate with each other. Further study is needed to mean longitudinal follow-up in 55 patients was 7.9 years (0.6 to
determine if severity of BPBP or other factors account for the lack 20.8 years).The progression pattern (Shapiro type) of LLD in 43
of correlation between these outcome measures. patients (> 3 scanograms) revealed; 25 (58%) patients- type-I, 10
(23%)- type II, 8 (19%)- type III pattern. 15/21 (71%) patients
PAPER NO. 380 who are at or are approaching skeletal maturity have had or are
Vastus Lateralis Adaptation by Serial Sarcomere on course for epiphysiodesis. The following variables: partial
(lower extremity) or complete (lower + upper extremity) hemi-
Addition One After Year Femoral Lengthening hypertrophy, IH or BWS, gender, and race had no significant
Jennette L Boakes, MD, Sacramento, CA (a – OREF) prognostic influence on predicted LLD (p value > 0.05). The
Jared R H Foran, MD, San Diego, CA (n) mean predicted LLD in left IH (n=25) and BWS (n=5) was 3.4
Samuel R Ward, PhD, Los Angeles, CA (n) cm and in right IH (n=29) was 2.4 cm. This difference was statis-
Richard L Lieber, PhD, San Diego, CA (a – OREF, National tically significant (p=0.027) only on combining the diagnosis.
Institutes of Health (NIAMS & NICHD)) Wilms tumor and/or hepatoblastoma developed in 4 children
Abstract: Skeletal muscle adaptation to chronic length change (7%) at a mean age of 5.2 yrs. 25/43 (58%) patients had
that occurs during distraction osteogenesis is poorly understood. continued increase in LLD with time, at the same proportionate
Many orthopaedic procedures are based on the assumption that rate (Shapiro type I). LLD in IH and BWS has a good prognosis
complete muscle adaptation will occur after surgery however with at most, surgical intervention being a “well-timed epiphys-
there are no data in humans to substantiate this assumption. iodesis” (71% in our study). Importantly, no patients required
Vastus lateralis fascicle length was measured during distraction leg lengthening.
and consolidation using ultrasound. Intraoperative sarcomere
PAPER NO. 382
length measurements were made and muscle specimens were
harvested at the index procedure and at the time of hardware Efficacy and Safety of Percutaneous Epiphysiodesis
removal. Normalized muscle cell elastic modulus and resting J Richard Bowen, MD, Wilmington, DE (n)
sarcomere length were determined by micromechanical testing Muharrem Inan, MD (n)
of the specimens and compared with those of five normal Gilbert Chan, MD, Wilmington, DE (n)
controls. While femoral length increased 10 percent, VL fascicle
Aaron G Littelton, BSc (n)
length increased by 200 percent, and in vivo sarcomere length
Paul J Kubiak, MD, Hermosa Beach, CA (n)
was unchanged. Average muscle cell elastic modulus revealed no
difference in the material properties of these fibers after length- Abstract: Epiphysiodesis is an accepted technique to correct limb
ening and compared to controls. Thus, the muscle adapted to length discrepancy in growing children. When initially intro-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS PEDIATRICS

limb lengthening by addition of sarcomeres by an amount that duced, the technique was an open method requiring surgical
was more than enough to compensate completely for the change dissection. In 1984, the technique was modified to be
in limb length. These data represent the first experimental results performed percutaneously. The aims of this study were to eval-
in humans where direct measurements of fascicle length and uate outcomes of percutaneous epiphysiodesis in 97 patients
sarcomere length were performed in the same individual under- and to assess complications and determine whether the correc-
going distraction osteogenesis. They demonstrate the remark- tion achieved will accurately follow the Moseley chart predic-
able capacity of the human VL muscle to adapt to a length tions. A total of 97 patients were reviewed retrospectively. F1fty
change of 200 percent. s1x girls and 41 boys with a mean skeletal age of 12.6 years
(range, 10 to 16 years) at the time of operation were followed
PAPER NO. 381 until skeletal maturity, a mean of 3.8 years (range, 1 to 10 years).
Timing of the epiphysiodesis was calculated using the Mosley
Leg-Length Discrepancy in Idiopathic straight line graph and patient were followed with scanograms
Hemihypertrophy and Beckwith-Wiedemann until skeletal maturity. The mean residual LLD in 88 patients at
Syndrome maturity was 1.3 cm (range, 0 to 3.5 cm). In nine patients, the
epiphysiodesis was combined with a femoral lengthening or
Purushottam Arjun Gholve, MD, New York, NY (n)
femoral shortening. The residual LLD in these nine patients was
Rebecca L Gaugler, BS (n) 3.3 cm at maturity (range, 0 to 6.5 cm). Minor complications
Kim E Nichols, MD (n) including knee effusion (n=2), superficial wound infection
Lindsey Close, MS (n) (n=1), and exostosis (n=3) occurred in six patients. Failure of the
Denis S Drummond, MD, Philadelphia, PA (n) epiphysiodesis was the only major complication seen (n=3). In
Richard S Davidson, MD, Philadelphia, PA (n) conclusion, this study shows complications are infrequent when
John P Dormans, MD, Philadelphia, PA (n) performing percutaneous epiphysiodesis and that the Moseley
Abstract: The natural history and significance of leg-length straight-line method accurately predicted the timing for percuta-
discrepancy (LLD) in children with idiopathic hemihypertrophy neous epiphysiodesis in all but one patient who had unpre-
(IH) or Beckwith-Wiedemann syndrome (BWS) are poorly dictable growth from hemihypertrophy secondary to a
defined. Shapiro reported type I progressive pattern of LLD in 48 hemangiomatosis.
(56%) of 86 patients with hemihypertrophy. This stu